
Class_8_B_ill. 
Book Jl^ 



Goipglitl^i?. 



CDPYRIGIiT DEPCSm 



A MANUAL 






OF 



PATHOLOGY 



BY 

GUTHRIE McCONNELL, M.D. 

PATHOLOGIST TO THE ST. LOITS SKIN AND CANCER HOSPITAL AND TO 
ST. LUKK's hospital; bacteriologist TO THE MISSOURI STATE 
BOARD OF health; FORMERLY ASSISTANT PATHOLOGIST 
. TO THE PHILADELPHIA CITY HOSPITAL 



Illustrated 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1906 






UBRARYofOONQRCSS 
Two Copies Roetlvfd 

OCT 101906 

OoBvrlfht entry 

CLA^ ^ XXc., N«. 
COPY B. 



Copyright, 1906, by W. B. Saunders Comi>any 



PRESS OF 
SAUNDERS COMPANY 
PHILADELPHIA 



f :■■ 



■^-PR-EFACE 



The purpose of this volume is not that it shall attempt 
to take the place of the more voluminous text-books on 
pathology, but that it shall enable the student especially to 
rapidly acquire the salient points of a subject. To this end 
the author has sought brevity, but has tried at the same time 
not to sacrifice clearness in the exposition of the material. 

If the student finds that this manual fulfils the above 
conditions the author will have accomplished his purpose. 

G. McC. 

St. Louis, Mo., August, 1906. 



CONTENTS 



PART 1— GENERAL PATHOLOGY 

CHAPTER I Page 

Pathology 17 

CHAPTER II 

Defects of Development 22 

CHAPTER III 

Disorders of Metabolism 26 

CHAPTER IV 

Circulatory Disorders 35 

Hyperemia 37 

Hemorrhage 40 

Thrombosis 42 

Embolism 46 

Infarction 47 

Edema or Dropsy 49 

Interstitial Emphysema 50 

CHAPTER V 

Retrogressive Processes 51 

Atrophy 51 

Degenerations 52 

CHAPTER \T 

Inflammation and Regeneration 74 

CHAPTER VII 

Cell Divisions 85 

CHAPTER VIII 

Progressive Tissue Changes 92 

Hypertrophy 92 



12 CONTENTS 

CHAPTER IX Page 

Tumors or Neoplasms -' 95 

Tumors of Embryonal Connective Tissue 100 

Sarcoma 100 

Tumors of Adult Connective Tissue 107 

Fibroma 107 

Myxoma 109 

Lipoma 109 

Chondroma iii 

Osteoma iii 

Myoma 113 

Neuroma 114 

Hemangioma 115 

Lymphangioma 115 

Odontoma 116 

Tumors of Epithelial Tissue 117 

Papilloma 117 

Adenoma 118 

Glioma 120 

Carcinoma 121 

Squamous Epithelioma 125 

Adenocarcinoma 127 

Syncytioma 130 

Teratoid Tumors 131 

Dermoid Cyst 131 

Teratoma 131 

Cysts 132 

CHAPTER X 

Infection and Immunity 133 

Theories of Acquired Immunity 135 

CHAPTER XI 

Vegetable Parasites 141 

Fungi 141 

Basidiomycetes 141 

Myomycetes 142 

Phycomycetes 143 

Blastomycetes 144 

Schizomycetes 144 

CHAPTER XII 

The Specific Micro-org.^nisms 152 



CONTENTS 13 

CHAPTER XIII Page 

The Specific Granulomata 169 

Tuberculosis 169 

Leprosy 172 

Glanders 175 

Actinomycosis 177 

Mycetoma 178 

Mycosis Fungoides 179 

Molluscum Contagiosum 1 79 

Rhinoscleroma 180 

Syphilis 180 

CHAPTER XIV 

Parasites 183 

Animal Parasites 184 

Protozoa 185 

Worms 192 

Arachnoidea 206 

CHAPTER XV 

Post-mortem Examination 207 

External Inspection 207 

Internal Inspection 208 

CHAPTER XVI 

Laboratory Technique 222 

Examination of Fresh Material 222 

Fixation and Hardening 224 

Decalcification 227 

Injection 229 

Imbedding Methods 229 

Cutting Sections 233 

Staining 234 

Nuclear Stains 236 

Connective Tissue Stains 242 

Elastic Fiber Stains 243 

Blood Staining 243 

CHAPTER XVII 

Bacteriological Methods 246 

Culture Media 246 

Staining Bacteria 251 

Methods for Staining Spores 254 

Staining of Flagella 254 



14 CONTENTS 



PART II— SPECIAL PATHOLOGY 

CHAPTER XVni Page 

The Blood 256 

Diseases of the Blood 259 

CHAPTER XIX 

Diseases of the Circulatory System 265 

Diseases of the Heart 265 

Cardiac Hypertrophy 272 

Cardiac Dilatation 274 

Diseases of the Arteries 274 

Diseases of the \'eins 279 

Lymphatics 2S0 

CHAPTER XX 

Diseases of the Respiratory System 282 

Diseases of the Nose 282 

Diseases of the Larynx 284 

Diseases of the Trachea and Bronchi 286 

Diseases of the Lungs 28S 

Circulatory Disturbances ^ 288 

Pneumonia 292 

Infectious Diseases 300 

Diseases of the Pleura 308 

CHAPTER XXI 

Diseases of the Digestive System 313 

The Teeth 317 

The Tonsils 317 

The Pharynx 319 

The Salivary Glands 322 

The Esophagus 323 

The Stomach 326 

Diseases of the Intestines 334 

Infectious Diseases 343 

Diseases of the Liver _ 354 

Infiltration and Degeneration 357 

Infectious Diseases 365 

Diseases of the Gall-bladder and Bile-ducts 370 

The Pancreas 374 

Diseases of the Peritoneum 380 



CONTENTS 15 

CHAPTER XXII Page 

Diseases of the Urinary Organs 385 

The Kidneys 385 

Diseases of the Ureter • 402 

Diseases of the Bladder 404 

Diseases of the Urethra 410 

CHAPTER XXIII 

Diseases of the Reproductive System 412 

The Male Organs 412 

The Penis 412 

The Testicles " 413 

The Seminal Vesicles 416 

The Prostate Gland 416 

Cowper's Glands 420 

The Female Organs 420 

The Ovaries 420 

The Fallopian Tubes 424 

Extrauterine Pregnancy 425 

The Uterus 426 

The Vagina 434 

The Vulva 436 

Diseases of the Mammary Gland 437 

CHAPTER XXIV 

OrSEASES OF THE MOTOK SvSTEM 443 

Bones 443 

Diseases of the Joints 450 

Diseases of the Tendons and Bursa . . 453 

Diseases of the \'oluntary Muscles 453 

CHAPTER XXV 

. Ductless Glands 457 

The Thyroid 457 

The Adrenals 458 

The Spleen 459 

The Lymph-nodes 464 

The Thymus Gland 468 

The Bone-marrow 468 

CHAPTER XXVI 

ASES OF THE BrAIN 470 

The Dura Mater . 470 



I 6 CONTENTS 

Page 

The Pia and Arachnoid 472 

The Brain 476 

The Pituitary Body 484 

CHAPTER XXVII 

Diseases of the Spinal Cord 486 

Special Diseases of the Spinal Cord 490 

The Peripheral Nerves 495 



Index. 



497 



A MANUAL OF PATHOLOGY 



PART I— GENERAL PATHOLOGY 



CHAPTER I 
PATHOLOGY 

"Pathology is. that subdivision of biology which has for 
its object the study of hfc in its abnormal relations." It 
is the science that treats of disease in all its aspects. 

By disease is meant any condition in which there is a 
variation from the normal aspect of the organism; it may 
be cither a structural or a functional deviation. 

Pathology may also be divided into two large classes, one 
in which the changes are structural, a condition known as 
morbid anatomy and histology. The other is where the 
changes are functional, morbid physiology. 

The main heading may be again subdivided into general 
pathology, that deals with abnormal processes common to 
the entire organism, such as inflammation, fever, etc., and 
special pathology, that includes the changes within special 
organs. 

Under etiology are considered the conditions giving rise 
to disease. They may be either predisposing or exciting. 

Predisposing causes are those that in any way lower the 
vitality of the individual and thus render him more suscep- 
tible; such as bad hygienic surroundings, ])oor food, bad 
air, noxious gases, fatigue, extremes of temperature, drugs, 
injury, pre-existing disease. 

2 17 



1 8 A MANUAL OF PATHOLOGY 

Exciting causes include mechanical forces, sudden extremes 
of heat and cold, electricity, poisons, parasites, and also cer- 
tain mechanical abnormalities, such as defects in the heart- 
valves. 

Although the causes are divided into these two classes, 
a predisposing cause if acting with great severity may readily 
excite disease. 

The individual may be the seat of two diseases, one acting 
primarily and another following secondarily. 

The latter may be either the direct result of the primary 
or may have nothing whatever to do wnth it. Infection of 
the lung by the tubercle bacillus gives rise to phthisis; later 
on there may be involvement of pleura or of intestine, or a 
person suffering from chronic nephritis will often die from 
a secondary pneumonia. 

Traumatism may cause disturbances of function more 
or less marked according to the extent, severity, rapidity, and 
duration of its action. 

If it takes the form of constant pressure, there will be mal- 
nutrition and atrophy of the part on account of the inter- 
ference with the blood-supply. If the pressure is intermit- 
tent hyperemia may occur and hypertrophy take place. 

When the force is sudden the lesions vary according to the 
instrument used. If sharp, there are lacerations; if dull, 
contusions. 

According to the locality there may be fractures and con- 
cussion. In all these injuries there is greater or less de- 
struction of tissue, followed by the phenomena of inflamma- 
tion, with either recovery or death. 

Temperature. — Following the local action of extreme heat 
a condition known as a hum results, in which there is relax- 
ation of the blood-vessels, exudation of serum, and possibly of 
blood. The extent of the injury to the tissues depends on the 
degree of heat and its time of action. According to the extent, 
burns may be divided into four classes : (i ) Hyperemia of the 
exposed surface; (2) extravasation of serum and lique- 
faction of certain cells, thus forming vesicles; (3) coagula- 
tion of the cellular protoplasm with resulting necrosis and 



PATHOLOGY 1 9 

extension into the deeper tissues; (4) charring of the tissues 
and extensive, deep involvement. 

Death may result from burns, either immediately from 
shock or later Trom exhaustion, from a perforating ulcer of 
the du^^-num, or from toxic substances formed either within 
the body or absorbed from the skin. There may be marked 
alterations within the blood and their action may prevent the 
kidneys from carrying on their functions. 

The cause of the duodenal ulcer is not clear, but may 
depend upon thrombosis of some small vessel and subse- 
quent digestion, by the gastric juice. As a rule, a burn, 
even of the first degree, will prove fatal if it involves one-third 
the surface of the body. 

If the exposure has been general the result will vary accord- 
ing to the cause, whether steam, dry air, or sun, etc. Expo- 
sure to dry air or sun may cause heatstroke or heat exhaus- 
tion. In the first there occur symptoms of heart failure, 
dyspnea, and coma, if severe. Usually the pulse is full and 
rapid, face flushed, very high temperature, dry skin, and 
labored breathing, unconsciousness and muscular relaxa- 
tion. In heat exhaustion the skin is moist, cool, pale, pulse 
small and soft, unconsciousness unusual, and temperature 
may be subnormal. 

Extreme cold will bring about conditions very similar to 
those resulting from heat, and will have various symptoms, 
according to whether the effects have been superficial or deep. 
In the former the tissue may completely recover, but in the 
latter the blood-vessels may be involved and gangrene follow. 

The primar}^ effect of cold is to bring about a contrac- 
tion of the superficial blood-vessels. This, however, gives 
way to a paralytic dilatation, on account of which more blood 
enters the chilled part and the entire body will be affected. 

If the* tissue should freeze during the stage of contraction, 
the part would appear pale; if during that of dilatation, it 
would be swollen and dusky in color. 

Electricity causes destruction of tissue either by the heat 
generated or by the resistance of the body to its passage. 

Death may result instantly from disturbance of the ner- 



20 A MANUAL OF PATHOLOGY 

vous system or there may be extensive and destructive burns. 
Sometimes there is involvement of internal organs. 

X-rays when a])plicd too closely or for too great a length 
of time occasionally give rise to a dermatitis or even to burns 
of the first, second, and third degrees. 

Barometric pressure may cause disturbances if it be 
either greatly increased, as in deep-sea divers or caisson- 
workers, or diminished, as in mountain-climbers and in 
persons ascending in balloons. In the latter the blood shows 
an increase in the number of red corpuscles, in their specific 
gravity, and in their hemoglobic content. 

Season also has a distinct elTect upon disease; pneumonia 
and bronchitis being most common in winter, typhoid fever 
and malaria in spring, yellow fever and enteric disorders in 
the summer. 

Intoxication. — A poison is a substance which when intro- 
duced into the living body in a relatively small amount will 
disturb the structure or functional activity. These sub- 
stances may be formed within the body through faulty metab- 
ohsm and give rise to endogenous or auto-intoxication; they 
may be introduced from without, exogenous intoxication. 

le endogenous may be (i) immediate and indiscriminate 
in their action or they may be (2) remote and selective. 

I . The first group includes the caustics and irritants. Their 
effects are the more marked the greater the concentration, 
and may be purely local. The poison may, however, be 
absorbed and give rise to remote effects. In this class belong 
the salts of the heavy metals, a few vegetable substances, 
and some animal products. 

The effects may vary from a slight reddening to marked 
necrosis and sloughing. They are brought about by ab-- 
stracting the water from the tissue, by coagulating the albu- 
mins and forming definite compounds with the elements. 
The effect depends on various conditions both of the indi- 
vidual and of the poison. If a patient has been addicted 
to, the use of a drug, a dose fatal to others may cause in him 
very slight disturbance. Sometimes a very large dose may 
cause vomiting, and the poison is in that way removed. 



PATHOLOGY 21 

2. Many of the first group come secondarily into this class 
by being absorbed and taken up into the blood. They may 
unite with the hemoglobin or they may bring about hem- 
olysis, a destruction of the red corpuscles. 

When the poison combines with the hemoglobin, forming 
methemoglobin, the union is so close that the oxygen can no 
longer be taken up and suppHed to the tissue. Death 
then results from a general asphyxia. Instead of death, 
cyanosis may develop, this commonly resulting from the use 
of coal-tar products. 

Strychnin is selective in its action in that it stimulates the 
respiratory centers and the motor nerves. Bromids depress 
them. 

Foreign bodies that are not living may cause disease by 
mechanically interfering with the functions of the body. The 
most important causes of disease are, however, baclcria, 
the lowest form of vegetable life. They are almost ubiquitous 
and give rise to many disturbances of function. It is not, 
however, always possible to prove the relationship between 
bacteria and disease. Koch has advanced four laws. They 
are: (i) The bacteria must be found in the diseased individ- 
ual; (2) they must be capable of cultivation u])on mcv a 
outside the body; (3) pure cultures introduced into a healthy 
animal must produce the disease in the animal; (4) the bac- 
teria must be recovered from the inoculated animal. 

Diseases caused by bacteria are capable of transmission 
from person to person and are generally termed injcclious. 
They may gain entrance into the body through abrasions of 
the skin and mucous membranes, through the air or by means 
of the digestive tract, through the gcnito-urinary tract, or 
they may be transferred from the maternal to the fetal blood 
in the uterus. 

Animal parasites may frequently ])e the cause of disease. 
To this class belong the various intestinal worms, and cer- 
tain blood organisms, as the plasmodium of malaria, the 
filaria, the trypanosomes, etc. 



CHAPTER II 
DEFECTS OF DEVELOPMENT 

A malformation is any deviation from the normal embry- 
onal development. This may be the result either of some 
disturbance taking place in the self-developing power of the 
embryo, or else due to some influence directly concerned 
with the maternal structures. The causes may be either 
internal, existing in the embryo itself, or external, those act- 
ing from without. 

If the development is only slightly imperfect the condition 
is called a maljonnaiion; if marked, it is a mo7ister. The 
df'''ect may occur within an individual or there may be two 
or more united individuals, the latter being either double or 
triple monsters. 

To have any serious malformation taking place, the causes 
must have begun to exert themselves very early in embryo- 
nal life. In such cases the lesions will generally be of such 
a nature that extra-uterine existence is impossible. It is 
probable that such take place before the third month. 

The malformations ])rought about by external causes usu- 
ally occur during the later period of fetal development. As 
a rule, they are not of sufficient gravity to prevent the child 
from living. 

Some of the departures from normal occur in different 
cases, but with about the same appearances; these are 
spoken of as typical and are due generally to some internal 
cause, harelip being such an example. If the malforma- 
tion is entirely unusual it is atypical, and results from exter- 
nal factors. 

If the variation is one that is present in either parent it 
is spoken of as an inherited abnormality, as in the frequent 



DEFECTS OF DEVELOPMENT 23 

occurrence of extra fingers or teeth in successive genera- 
tions; is also seen in the way in which certain diseases are 
transmitted from parent to offspring. 

If the abnormahty passes over one or two generations 
before reappearing, the condition is known as atavism. 

Varieties of Congenital Malformation. — The chief 
single forms of deviation are divided as follows: 

1. Aplasia, or complete failure of development, which may 
be either general or local. If general, abortion usually results 
and the embryo is cast off. It may, however, be infiltrated 
with hme salts, forming a lithopedion. Examples of the 
local form are absence of parts of the body, as fingers, toes, 
and internal organs. This condition may prevent life, as 
in the absence of the brain or heart. 

2. Hypoplasia is the failure of parts of the body to reach 
their full development, as in small size of limbs or of the 
brain. It is seen in cases where one kidney may be very 
large and the other very small. 

3. Incomplete union along the line of closure of the fetal 
arches may be anterior, posterior, or lateral, such as extrit- 
sion of viscera, spina bifida, and harelip. 

4. There may be an abnormal union of parts, as of the 
lower extremities. 

5. Occasionally there is a duplication of parts, particularly 
of the digits; sometimes of the internal organs, as the spleen 
and pancreas. 

6. Abnormal location of viscera. In these cases all the 
single organs are transposed, the heart and spleen on the 
right, the liver on the left side. 

7. Obstruction of the external openings, mouth, anus, 
vagina, etc. 

8. Persistent misplaced fetal structure, which may even- 
tually give rise to neoplastic formations, usually cystic. 

g. Anomalies of sex — hermaphroditism, which may be 
cither true or false. In the early stages the embryo is bisex- 
ual, but finally one set of organs undergoes a perfect develop- 
ment, with slight traces only of the subsidiary organs. In 
the true form both sets of organs would be present, well devel- 



24 A MANUAL OF PATHOLOGY 

oped. This condition is so rare that it is said not to cxi^t, 
one case only having been reported. 

In false hermaphroditism the malformation depends upon 
abnormahties of the external genitalia. 

Double Monsters. — In these there is a duplication of the 
whole body, the hahes being attached to each other, or a du- 
pHcation of either caudal or cephalic end. Such monsters 
are always of the same sex and are usually joined at corre- 
sponding parts, as head, thorax, or sacrum. They arise 
from a single ovum and blastodermic vesicle, and the cause 
that determines their formation must exert its inlluence at 
the earliest stage of development, probably during tlie forma- 
tion of the primitive streak and medullary groo\e. 

They may result from: 

1. Two embryonic areas arising within a single l)lasto- 
dermic vesicle and continuing to grow. 

2. Two ])rimitive streaks and two mcdullarv folds aris- 
ing within a single embryonic area and eitlur remaining 
separate or merging. 

3. A single primitive streak witli either i);irtial or com- 
plete doubling of the medullary groove. 

4. The duplication may take ])lace late in the develop- 
ment and affect only single parts. 

The first three cause abnormalities along tlie main axis 
of the body; in the fourth, the variations lie to one side. 

Twins and triplets in a way belong to the class of mon- 
strosities, as they are a reversion to the lower types, in which 
multiple births are common. 

The twins may be equally developed and of the same size, 
or one may be larger and more advanced. They will in the 
first case usually live; in the second they sometimes con- 
tinue to exist. 

The varieties of double monsters arc named by adding the 
word ''pagus" (from pag, meaning ''to fasten") to the name 
of the part of the body by which they are attached, as xipho- 
pagi, when joined by the xiphoid cartilage; cephalo-pagus 
if bv the heads. 

These monstrosities may or may not live, according to 



DEFECTS OF DEVELOPMENT 25 

the development of the internal organs. In many cases 
each individual has had well-developed and separate organs 
and the two have hved for many years. 

Sometimes one of the twins may take up the nutrition at 
the expense of the other, with subsequent increase in size. 
The larger of the two is called an auiosite, and the other a 
parasite. The latter is generally imperfectly developed. 

The abnormalities of the various important organs will 
be considered in their respective chapters in Part II. 



CHAPTER III 
DISORDERS OF METABOLISM 

By metabolism is meant those physiologic processes brought 
about in Hving tissue by means of which the individual is 
able to form new tissue and reintegrate the old. Under this 
head comes the rejection of those substances that are unlit 
for use in the bodily economy. 

When the tissues are unable to carry on these molecular 
exchanges a pathologic condition exists. This may be either 
functional or structural, the latter generally being secon- 
dary to the former. 

Metabolism may be divided into two classes according to 
whether simple substances are built up into complex, or the 
complex broken down into the simple. The building up or 
constructive variety is called anabolic metabolism; the break- 
ing down or destructive, catabolic metabolism. 

By means of catabolism the ''end products," those sub- 
stances not required by the body, arc formed ; such as urea, 
water, etc. Anabolism is concerned in the rearranging of 
molecules so as to render them suitable for food. 

A food is a substance that will form new or reintegrate 
old tissues. It may be either in excess or in diminution, 
or may vary in quality, the amount required depending upon 
the activity of the individual. 

The assimilation of food depends upon the presence within 
the gastro-intestinal tract of certain digestive ferments, 
which may vary greatly in quantity. 

The protcid substances are acted upon by the pepsin in the 
stomach and the trypsin from the pancreas. Pepsin acts in 
an acid medium, trypsin in an alkahne. The necessary acid 
in the stomach is the hydrochloric. Changes from the nor- 

26 



DISORDERS OF METABOLISM 27 

mal amount of pepsin are unusual, but there may be great 
variations as far as the acid is concerned. It may be in- 
creased, hyperchlorhydria; diminished, hypochlorhydria; 
or absent, ^achlorhydria. If absent or much 'diminished, 
the food not being properly digested will undergo fermen- 
tation. If there be any obstruction at the pylorus the 
stomach will tend to dilate. 

The carbohydrates are acted upon first in the mouth by the 
salivary ferment, ptyalin; then in the intestine by amy- 
lopsin, a ferment derived from the pancreas. 

The jats are acted upon by steapsin, a pancreatic ferment, 
and by the bile. 

The condition of the individual depends upon the assim- 
ilation of the food, which may be abnormal in quantity or 
quahty. 

If the quantity taken up by the individual is diminished 
either by lack in amount or by being deflected from its 
proper channels, certain pathologic conditions will result. 
These may be starvation, in which case the bodily weight 
diminishes, the temperature falls, and the energies all fail. 
At first the reserved food is called upon. The circulating 
proteids arc first used up, then the glycogen, and afterward 
the fats and the muscles. The heart and the central ner- 
vous system are the last structures to be involved. The 
organs become smaller, the excretions and secretions are 
gradually suspended. In the blood the leukocytes become 
much fewer, although the red cells appear in normal num- 
ber. This is probably due to the loss of the blood-serum. 
Death takes place slowly, either from exhaustion, disorders 
of metabolism, or by terminal infections. 

In marasmus, a term applied to babies and old people, the 
wasting away takes place more slowly than in starvation. 
In it the trouble is very frequently not due to lack in quantity 
of food but to improper assimilation. 

If during the course of a definite disease these symptoms 
of slow starvation appear, the condition is called cachexia. 
In it there is a peculiar yellowish color of the skin and also 
a marked anemia. 



28 A MANUAL OF PATHOLOGY 

Rachitis or rickets is a condition of childhood that is indi- 
cated by structural changes of the bones, particularly those 
of the pelvis and of the lower extremities. There is a lack 
of proteids and of inorganic salts. It is generally accom- 
panied by gastro-intestinal disturbances. 

If larger amounts of food are taken than are necessary for 
the bodily requirements, the excess will be carried through 
the intestines unacted upon. It will cause an overfilling of 
the blood-vessels or else there will be an excessive deposit 
of fatty tissue, this condition being known as obesity or poly- 
sarcia. It may be either the result of excessive assimilation 
of the carbohydrates or of diminished oxidation of the fat- 
forming substances. 

In asphyxia there is a lack in the amount of oxygen and 
an increase in the carbon dioxid. In this j)rocess there is 
first a period of increase in the inspiratory efforts, then in the 
expiratory, and finally exhaustion. After death the heart, 
particularly the right side, is found to be distended with 
blood. 

Dyspnea is a slight lack of oxygen, sufficient to stimulate 
but not to depress the respiratory centers. Cyanosis, a 
bluish color of the skin, particularly of the face, then appear- 
ing. Apnea is a condition in which there is a period when 
no respiratory action takes place. 

Abnormalities in the secretions of the organs may cause 
marked disturbance. The secretions may be either inter- 
nal or external. The external pass directly from the glands 
by means of ducts. The internal pass slowly into the blood, 
which carries them to all parts of the body. 

The thyroid secretion, when lessened or absent, gives rise 
to the condition known as myxedema. In this the skin 
becomes much swollen and firm, particularly in the region of 
the face. The skin will not pit on pressure nor are the 
dependent portions affected. The hair frequently falls 
out, the voice undergoes changes, and there are commonly 
decided disturbances of mentality. If sheep's thyroid gland 
is given in such cases, there is frequently a decided improve- 
ment. 



DISORDERS OF METABOLISM 29 

Cretinism is a very similar but more severe condition result- 
ing from disease of the thyroid during intra-uterine life or 
in early childhood, usually appearing during the first year. 
The child does 'not develop, remains a dwarf, there is more 
or less complete loss of mind, the lips are very thick, tongue 
large, and the abdomen very pendulous. Frequently sev- 
eral members of a family are found to be suffering from it. 
The state is also occasionally markedly hereditary. 

If the thyroid secretion be increased, there may result 
exophthalmic goitre, or Basedow's disease. It is character- 
ized by enlargement of the thyroid gland, paroxysms of 
palpitation of the heart, bulging of the eyes, and nervous 
excitement. In this the administration of sheep's thyroid 
increases the symptoms. 

The relationship between the thyroid gland and general 
disease is not clearly understood. There appears to be 
distinct bearing upon the nervous system and also upon the 
metabolic processes taking place within the body. The 
active principle seems to be "thyroidin," a substance that 
contains nearly lo per cent, of iodin. 

The secretion of the adrenals seems of marked importance, 
as disease of or removal of those bodies causes severe disturb- 
ances in the individual. If completely removed, collapse 
and death occur within a few hours. When the breaking 
down has taken place slowly, a condition known as Addison's 
disease results. In it there is an increasing weakness, accom- 
panied by anemia, emaciation, and a peculiar bronzing of 
the skin and mucous membrane of the mouth. 

The action of the adrenal secretion seems to be more upon 
the vasomotor condition. When applied locally the vessels 
will contract, and if injected into the circulation will cause 
a rise in blood-pressure. This is due to the contraction of 
the arterioles. 

Whether or not it has a relation to the pigmentation of the 
skin and to the cachexia is not settled. 

The secretion of the pituitary body seems to bear definitely 
upon the nutrition of the tissues. When diseased the con- 
dition of acromegaly is generally present. In it there is a 



30 A MANUAL OF PATHOLOGY 

marked enlargement of the bones of the face and of the ex- 
tremities. The enlargement is due to an actual hypertrophy 
of the parts involved. Accompanying this there is usually 
some interference with speech, and the memory is slightly 
affected. 

In the pancreas, besides the three external secretions, there 
is also an internal one. It seems to be chiefly concerned in 
carbohydrate metabolism; it is a glycolytic ferment. 

Diabetes is a disease in which the carbohydrates are not 
properly assimilated and it is characterized by the persistent 
appearance of sugar in the urine. In this way it differs from 
alimentary glycosuria, in which the sugar appears transi- 
torily. This is due to an incomplete arrest of sugar in the 
liver, some of which escapes into the urine. 

In diabetes there is always a preceding increase of sugar 
in the blood, glycemia. About o.i per cent, is normal; in 
increased amount it acts as a poison upon the proto])lasm of 
the cells and increases nitrogenous metabohsm. The ex- 
cess is eliminated by the kidneys and appears in the urine 
as dextrose, no matter in what form the sugar was con- 
sumed. 

The generally accepted opinion as to the cause of diabetes 
is that it is due to disease of the pancreas. Extirpation of 
that organ gives rise to a glycosuria closely resembling 
diabetes and terminating fatally. 

The structures most intimately concerned are the islands 
of Langerhans. These are most numerous in the tail or splenic 
end of the gland and are supposed to regulate the metab- 
olism of sugar. If the lesion involve these structures, 
then diabetes ensues; if, however, the head end is affected 
there may be no glycosuria, as the islands are not found in 
that portion. 

The lesion of the islands belongs to the group of hyaline 
degenerations. There is the formation of a homogeneous 
substance that stains with the acid dyes but does not give the 
amyloid reaction. 

There may also be an interstitial change that affects the 
parenchyma of the organ as well as the islands of Langerhans. 



PISORDERS OF METABOLISM 3I 

All cases of diabetes cannot, however, be ascribed to dis- 
ease of the pancreas, as injuries to the floor of the fourth 
ventricle of the brain will give rise to the same symptoms. 

Disorders of excretion may give rise to abnormal condi- 
tions, either by valuable products being thrown off unused 
or by the retention of harmful substances. 

In the daily excretion of urine from 30 to 40 grams of urea 
are disposed of. If this substance is retained within the 
body, uremia results. More recent investigations would 
indicate that it is not so much the retention of urea that 
causes the symptoms as the presence of the compounds from 
which urea is formed, particularly ammonium carbamate. 

In the urine there are several toxic substances. Although 
no one of these alone will produce uremia yet the combina- 
tion of all may cause it. 

Uremia may be acute or chronic. In the former there 
develop severe convulsions, vomiting, blindness, and coma, 
with death frequently. In the chronic form there is head- 
ache, drowsiness, and slowly developing coma. 

A condition closely allied is that of eclampsia, in which 
pregnant women present symptoms similar to those of ure- 
mia. It may be due to the retention within the blood- 
serum of toxic substances probably derived from the placenta. 

Gout or podagra is a disease in which there is deposited 
within the joints, in the articular cartilages, uric acid and its 
compounds. It generally affects the small joints of the 
hands and feet, particularly the big toes. These salts may 
be deposited elsewhere, as tophi in the cartilages of the car, 
and in the meninges. As a result of these deposits the joints 
may be much deformed. Lesions of other portions of the 
body are usually ])rcscnt. There is a marked tendency 
toward the formation of connective tissue in the form of 
interstitial nephritis and of arteriosclerosis; fatty changes 
also take place in the heart and liver. Gout usually appears 
after middle life in those who have lived very well, drunk 
plenty of wine, and have not taken exercise. It is a chronic 
disease, but exhibits periods of acute and painful inflamma- 
tion lasting several days. 



32 A MANUAL OF PATHOLOGY 

The salts concerned are the sodium biurates and quadri- 
urates, uric acid existing in the blood in the form of the lat- 
ter. The soluble quadriurates circulating in the blood, if 
in the presence of uric acid and sodium salts in excess, are 
precipitated as insoluble crystalline biurates. 

In oxahiria and phosphaliivia there is an excess of either 
oxalic acid salts or of phosphates. The presence of oxalic 
acid is thought by some to be due to the amount ])resent in 
the vegetable matter consumed, while others tliink it is the 
result of deficient oxidation of the carbohydrates. It is of 
chief importance in the formation of calculi, it being pre- 
cipitated in the crystalline form mainly when there is an 
increased amount of calcium in the urine. 

The phosphoric acid exists in the form of the phosj)hates of 
magnesium, ammonium, and sodium. These may form cal- 
culi in the bladder when they occur in excessive amount in an 
alkaline urine, as they remain in solution if the reaction is acid. 

Acetone and diacetic acid arc often found in the blood and 
urine in the later stages of diabetes. 

The hile may vary in amount and consistency and may be 
prevented from passing into the bowel. The normal amount 
secreted varies from 500 to 1000 c.c. in a day. It is com- 
posed chiefly of water, Init contains bile salts, cholesterin, 
lecithin, fat, and coloring sul^stances. The salts are the gly- 
cocholate and the taurocholate of sodium. The important 
pigments are bilirubin and biliverdin, l;oth of which are 
derived from the blood. Bilirubin undergoes oxidation to 
form various other pigments. It resembles hematoidin, 
and the toxic effects of the retention of bile seem to depend 
upon its presence, as when the bile is freed from its coloring- 
matters by filtration it is only one-third as toxic as in its 
original condition. 

If there should be any obstruction to the outflow of bile 
the condition known as icterus or jaundice follows. This 
obstruction may result from a catarrhal condition or a sten- 
osis of the bile capillaries, inflammations of the common bile- 
duct, or of the papilla. It may be due to foreign substances, 
such as gall-stones, inspissated mucus, round-worms, or 



DISORDERS OF METABOLISM 33 

tumors within the large duct, or to pressure upon it from 
without. The jaundice is due to the absorption of the bile 
into the general circulation by means of the veins or lymphat- 
ics. A large amount of it is eliminated by the kidneys, 
while the excess is deposited within the connective tissues. 

As a result of the absorption of the bile the skin is at first 
yellow, but if the condition continues for some time the pig- 
ment oxidizes and becomes greenish in color. This discol- 
oration will be seen in the sclera, the lining of the arterial sys- 
tem, the mucous membranes, and in most secretions and exu- 
dations, normal or pathologic. The heart's action is fre- 
quently slowed (bradycardia) to 50 or even 20 beats a minute. 

The effect upon digestion may be quite marked. There is 
found an excessive amount of fat in the feces. The stools 
become very light in color, due to the absence of hydro- 
bilirubin, and may be very offensive. There may be some 
interference with the outflow of the pancreatic enzyme, which 
would have a distinct effect upon the amount of fat present 
and also upon the color of the feces. 

Sometimes there are marked nervous symptoms, probably 
the result of the presence of the biliary acids and salts in the 
circulation rather than due to the pigments. 

Another form of jaundice is that of hematogenous ori- 
gin. It occurs when no obstruction to the outflow of bile 
can be found. Although bile cannot be formed in any other 
])lace than in the liver cells, there are cases in which a gen- 
eral yellowish discoloration takes place without any hepatic 
lesion being present. It occurs in certain infectious diseases, 
as in yellow fever, malaria, etc., in poisoning by venom and 
toluylendiamin, and in the new-born in the form of icterus neo- 
natorum. In all these conditions, particularly in the last 
named, there is a very marked destruction of the erythro- 
cytes. The blood-pigment is changed into bile-pigment and 
thus stains the tissue. This form may be due to some ner- 
vous disturbances that cause a contraction of the circular 
muscles of the bile-ducts. It may be that there is an in- 
crease in the viscosity of the bile on account of the presence 
of the blood-pigments, and in that way the ready outflow is 
3 



34 A MANUAL OF PATHOLOGY 

prevented. It has also been shown that the concentration of 
the bile Is associated with an inflammatory condition of the 
bile-ducts. 

Besides the secretion of bile the liver also forms urea and 
glycogen, but these two latter bodies are carried off in the 
blood. 

Disturbances within the intestine may bring about a con- 
dition of putrefaction accompanied by various symptoms 
of self-intoxication. The feces are made up of the remnants 
of digestion and of waste products. Their odor is due to 
the presence of indol and skatol. 

The intestinal disturbances are due chiefly to the presence 
of bacteria and their products. Fermentation may take 
place in the stomach with the formation of acetic, lactic, or 
butyric acids, or of alcohol. It results from the breaking 
down of the carbohydrates. In the intestine the proteids 
may undergo putrefaction and produce amido acids, or 
aromatic bodies, as acetone, tyrosin, cresol, skatol, and indol. 
Ptomains may be formed and give rise to many symptoms. 
These bodies resemble quite closely many of the vegetable 
alkaloids and give rise to symptoms similar to those result- 
ing from the drugs. 

As a result of these disturbances diarrhea may occur. In 
this condition the feces are too soft and the bowel move- 
ments too numerous. It is an attempt to free the body of 
the irritating substances and may relieve the patient. The 
diarrhea may be due to increased rapidity of peristalsis, in- 
creased secretion of the intestine, diminished absorption by 
the large intestine, or disturbances of the controlling ner- 
vous mechanism, these depending upon many causes. These 
may be mechanical, inflammatory, infectious, obstructive, 
hepatic, and pancreatic. 

Constipation or coprostasis is a condition in which the bowel 
movements are infrequent and the feces hard and dry. If 
the retained w^aste products are absorbed into the body, 
copremia, a form of auto-intoxication, results. Constipa- 
tion may be due to obstruction, to impairment of peristalsis, 
abnormal consistency of the feces, or to impaired sensibility 
of the center of defecation in the spinal cord. 



CHAPTER IV 
CIRCULATORY DISORDERS 

The circulation of the blood is maintained chiefly by two 
forces — the rhythmic contraction of the heart muscle, and 
the elasticity of the arteries. Other factors concerned are 
the compression of the veins by the muscles and the inspira- 
tory action of the chest. 

As these are the chief factors, any abnormality within them 
will bring about more or less general disturbances of the cir- 
culation. To these may be added alteration in the quantity 
or quality of the blood itself. According as to whether the 
effect is more marked in the systemic or in the pulmonary cir- 
culations the disturbances are more or less widely distributed. 

The circulatory disorders may be cardiac in origin and 
either the result of muscular or valvular lesions. If muscu- 
lar, there may be an excessive or, what is more common, a 
diminished action. 

The former is seldom lasting, but while present causes a 
rise of blood-pressure, an increased amount of blood within 
the vessels in the part involved, and an increase in the rate of 
How. If the overaction should be long continued, as a result 
of hard work or by constant stimulation, there would be 
hypertrophy of the left ventricle. 

Diminished activity is more common and more important 
than the above. It may be brought about in many w^ays. 
It may be the sequel of a heart muscle weakened by the 
infectious fevers or other diseases, by poisons, by lack of nour- 
ishment caused by anemia, or by a blocking of the coronary 
arteries. It may be the result of nervous disturbances with 
no apparent lesion of the muscle, or it may be the result of 
some \'alvular disorder. 

35 



36 A MANUAL OF PATHOLOGY 

The valvular lesions and their scquelcT will be discussed 
in another chapter. 

Sometimes it results from pressure from the outside — 
that exerted by collections of fluid in the pericardium, in the 
pleurcT, or by tumors or adhesions. 

As a result of the weakened circulation there is an accumu- 
lation of blood in the venous circulation. If the failure is of 
the left ventricle, there will be a damming back of the blood 
in the left auricle and in the pulmonary circulation. If 
the right heart remains capable, the engorgement will go 
no further, but when it fails the right auricle becomes dis- 
tended and a condition of general i)assive congestion ensues. 

In all cases there is a decrease of arterial and an increase 
of venous pressure. 

When the heart's action has become much weakened it 
will be found that the blood tends to gravitate to the more 
dependent portions, giving rise to hypostatic congestion. It 
occurs in the late stages of severe fevers and when death has 
taken place very slowly. The dependent tissues will become 
livid through the accumulation of blood, edematous from 
the escape of fluid from the blood-vessels, and sometimes 
bedsores may result. A frequent occurrence is a collec- 
tion of blood within the lungs, a condition known as hypo- 
static pneumonia. 

The changes within the arteries may be either organic or 
nervous (vasomotor). Their elasticity may be diminished, 
and their caliber increased or diminished. The alteration 
in caliber may be due to changes within the tissues or to 
disturbances of the vasomotor control. 

If there is a paralysis of the controfling nerves, the vessels 
dilate and hyperemia results. On the other hand, stimula- 
tion will cause contraction and subsequent anemia. When 
sufflciently marked, there will be an increase in the blood- 
pressure, interference with the heart's action, and venous 
congestion. 

The most common organic disturbance is a sclerosis of 
the vessel wall, a condition leading to constant interference 
with the arterial circulation. Generally a hypertrophy of 



CIRCULATORY DISORDERS 37 

the left heart follows. If, however, the sclerotic changes 
are very widely distributed, instead of hypertrophy there 
may be a dilatation, on account of the resistance being too 
great for the heart to overcome. 

Changes in the quantity of the blood, either an increase 
or a decrease, are generally only temporary, and soon read- 
just themselves, either through a contraction or a dilatation 
of the vessels. 

Alterations in the quality have a marked effect upon the 
circulation, probably through the direct action of the toxic 
substances upon the vessel walls or upon the terminal nerve 
filaments. 

Hyperemia. — General Hyperemia.— Thar i: may be an 
increase throughout the body of the total volume of blood. 
This seldom remains for any length of time, as the various 
excretory structures of the body get rid of it. The condi- 
tion known as plethora is the result of persistent overeating 
and drinking. Is usually associated with a hypertrophy of 
the left ventricle. 

Local hyperemia is an increase in the amount of blood in 
a part of the body. It may depend upon either an increased 
supply to the ])art or be due to a diminished outflow — in one 
case a dilatation of the arteries, in the other an obstruc- 
tion of the veins. The first is known as active or arterial, 
the second as passive or venous hyperemia. 

Active hyperemia is an excess of arterial ])lood in a part. 
It occurs with increased functional activity and increased 
metabolism. It may be brought about through the central 
nervous system or by direct stimulation of the peripheral 
nerves. Any pathologic condition that will bring about a 
local dilatation of the arteries will cause active hyperemia. 

The spinal cord or a nerve may be pressed upon as the 
result of a tumor or of an injury, and a paralytic dilatation 
occurs. The same condition follows the use of certain drugs 
acting peripherally either upon the muscular coat of the 
artery or upon the local nervous mechanism, or both. 

In active hyperemia the part alTected is redder than nor- 
mal and more or less swollen as the result of the increased 



38 A MANUAL OF PATHOLOGY 

amount of arterial blood that it contains. The tempera- 
ture is higher than in the surrounding parts, but never 
higher than that of the internal organs. There is also an 
increase in the rate of the blood-flow. 

This form of hyperemia if continued for some time is fol- 
lowed by (i) hypertrophy of the part on account of the in- 
creased nutrition, (2) parenchymatous degeneration from 












5 0-0,^ o-^ " , , _ , ■ : 






>-» 






'^ ^n, 



C ?.^^ ^ o ^ ^ ■" ^ 









Fig. I. — Passive Hyperemia of the Lung. X 250 (Diirck). 

I, Ectatic and distended blood-vessels, filled with l)l()()d; 2, engorged 
and tortuous capillaries; 3, lumen of alveolus; 4, increased interlobular 
connective tissue; 5, cells, containing blood-pigment, within the alveolar lu- 
men; 6, free, amorphous blood-pigment. 



over-nutrition or over-stimulation of the cells, and (3) a pro- 
liferation of the connective tissue around the l)lood-vessels. 

It is found as one of the phenomena of inflammation. 
Postmortem, it cannot be recognized on account of the con- 
traction of the arterial walls, which drives out the blood. It 
may persist in the kidneys. 



CIRCULATORY DISORDERS 39 

Passive hyperemia is an excess of venous blood in a part. 
It is the result of a distention of a vein on account of some 
obstruction to the outflow of the blood. This can be caused 
by obstruction within the veins or capillaries, as by thick- 
ening of their walls, by thrombi, or by pressure from without, 
as from a tumor. A common cause for general passive 
hyperemia is a lesion of the heart-valves. The circulation 
will continue slowly unless the venous pressure becomes as 
great as the arterial, when it will stop, a condition known 
as stasis. 

A part the seat of passive hyperemia becomes cyanotic, 
swollen, edematous, cooler than normal, and its function 
less. The rate of blood-flow is lessened. The edema is 
due to the escape of fluid from the blood. If severe, red 
corpuscles may escape. 

Following long-continued passive hyperemia the tissues 
will undergo a fatty degeneration, on account of the decreased 
nutrition, or even necrosis and gangrene may result. There 
may also be some increase in the amount of connective tis- 
sue. Pigmentation from escaped hemoglobin is not uncom- 
mon — brown atrophy. 

When stasis occurs the blood- corpuscles slowly collect in 
the smaller vessels, the plasma is exuded, and the cells become 
packed closely together. Finally the outline of the cells can- 
not be seen and the vessels appear to be filled with coagu- 
lated blood. Such is not the case, as when the circulation 
is re-established the corpuscles separate and move along as 
usual. 

Local anemia or ischemia is the condition in which the 
part contains less than its normal amount of blood. It is 
most commonly due to obstruction by pressure of the flow 
of blood into a part. This may be due to tight bandaging, 
pressure from a tumor, or to thrombi or emboli, or to 
changes in the wall of the vessel. 

Disturbances of the vasomotor system may bring about 
marked lesions. If there is a good collateral circulation the 
area to which the obstructed vessel goes may show very 
slight change. If such is not the case, infarction may fol- 



40 A MANUAL OF PATHOLOGY 

low. An anemic area is pale in color, temperature lower, 
and functional activity decreased. 

Hemorrhage is the escape of all the constituents of the 
blood through the walls of the heart or of the blood-vessels. 
It is divided into three classes, according to the vessel from 
which it escapes, as arterial, venous, or capillary. 



J8 






"t^ 4t 






^*- 



FlO. 2. 



^:^- e^ 





^ .<..o^C."^* 




. V '^.-r ■ e 




^ %'-" 


o 


v--'*' 




' o " ,.- ''"o o 


K 


o-l, 'G'' ^' 


o 


<?0 -,Vv _^— --'"'^ 






• 
c- 




V •»!' '. G 




^ ?-^#...:-:^ ^^ 





-Multiple Capillary Hemorrhages in the Cerebrum He- 

mat.-eosin. X 270 (Diirck). 

I, Cerebral substance; 2, engorged capillaries; 3, small artery with 

hemorrhagic infiltration of its walls; 4, hemorrhage by diapedesis in the 

tissues around a small artery; 5, smaller hemorrhagic foci withou any 

connection with any blood-yessel yisible in the section ' 

It may occur by rhexis, in which case there is a demon- 
strable destruction of the vessel wall, or by diapedesis, when 
there is no discoverable lesion. The latter form occurs only 
from veins and capillaries. The method of escape of the 
corpuscles is not clear, but is generally supposed to take 



CIRCULATORY DISORDERS 41 

place through the stigmata of the lining endothelium. Hem- 
orrhage by rhexis may be primary or immediate, and sec- 
ondary or recurrent; the first following immediately, upon 
laceration of the vessel wall, the second occurring some 
time after the original injury. 

Hemorrhages may also be designated by special terms 
according to the area involved. PetcchicB are minute, cir- 
cumscribed hemorrhages. Ecchymoses are of moderate 
extent; are what are commonly known as bruises. Extrav- 
asations^ sufjiisions, and siigillations are conditions in 
which extensive areas are implicated. A hematoma is a 
collection of blood within a solid tissue. A hemorrhagic 
infarct is a circumscribed hemorrhage within tissues, the 
result of the obstruction of an end-artery. 

A hemorrhage may also have a special name according 
to its locality. According to the cavity in which it collects 
there may be a hemothorax, hemopericardiiim, etc. Ac- 
cording to its method of escape from the body it may be 
known as epistaxis, bleeding from the nose; hemoptysis, 
from the lungs; hematuria, from the urinary tract, etc. 

A peculiar form of hemorrhage is tliat known as liemo- 
philia. In it no lesions can be discovered, but severe bleed- 
ing takes place as the result of most trivial injuries. It is 
generally hereditary, and transmitted througli the daughters 
to their male descendants. The reason for the bleeding 
may be that the coagulability of the blood is decreased, 
but there may also be changes both in the blood and the 
vessels. 

Hemorrhage by rJiexis may be caused by: (i) Increased 
blood-pressure, particularly in those cases in which, the blood- 
vessel walls being diseased, their elasticity is diminished. 
(2) Disease of the vessels, in which the walls become so weak 
that they are unaWc to withstand the normal pressure. (3) 
Traumatism, injury of some form sufficient to cause a 
lesion of the vessel wall. 

Hemorrhage by diapedesis may follow in the course of 
(i) certain diathetic diseases, as scurvy, purpura hemor- 
rhagica, leukemia, hemophiUa, etc.; (2) in severe in/iam- 



42 A MANUAL OF PATHOLOGY 

matio7is; (3) in severe hyperemia, either active or passive; 
(4) in certain forms of poisoning, particularly that by snake- 
bite; (5) alterations oj innervation; (6) in hemophilia. 

Spontaneous arrest of hemorrhage takes place in two ways : 
(i) When a vessel is injured its walls contract, and the 
lumen is diminished in size. The vessel also being elastic 
retracts within the surrounding tissues. (2) The blood 
coming in contact with abnormal surroundings coagulates, 
just outside, then upon, and fmally within the vessel; this 
latter being known as a thrombus. In this way the vessel 
becomes plugged and the bleeding ceases. Another factor 
is that, as a result of the escape of large amounts of blood, 
the heart becomes weaker, even to a point where syncope 
may result; following this the blood-pressure falls and is 
unable to displace the clot. 

The results of hemorrhage vary according to the amount 
of blood lost. If the amount has been small, there will be 
no ill effects; if comparatively large, weakness and uncon- 
sciousness; if very large, death w^ill result from cerebral 
anemia. When the blood collects within the tissue, various 
changes take place. It undergoes coagulation, a condi- 
tion in which fibrin factors acted upon by fibrin ferments 
form a solid body known as fibrin. The greater the amount 
of fibrin, the more difficult is it for the tissue to recover. The 
fluid elements are first taken up, by absorption, by the lymph- 
atics. The corpuscular elements and the fibrin break up, 
hemoglobin is set free, and the particles are scattered through 
the tissue. The greater part will be slowly removed by the 
phagocytes, but some will remain. If the coagulation has 
been extensive the tissues may undergo a liquefaction necro- 
sis, giving rise to a cyst. 

Thrombosis is the coagulation of the blood within the 
vessels during life. It may depend upon changes within 
the blood, changes in the cardiovascular structures, and 
diminution of the velocity of the blood- flow^ 

The changes of the blood are those which tend to increase 
its coagulabihty. Certain chemical and physical substances 
when in the circulation mav Hberate fibrin ferments and 



CIRCULATORY DISORDERS 43 

thus cause thrombosis. The toxins of pneumonia and of 
diphtheria are especially active. 

The lesions of the vessel walls are particularly important. 
Fibrin will be deposited upon the wall of the heart or blood- 
vessels whenever the nutrition of the endotheHum of that wall 
is impaired. Diseases leading to the roughening of the endo- 
theHum, particularly arteriosclerosis, are important causes. 
Inflammation of neighboring structures may bring about 
changes within the intima. Ligation of a vessel causes an 
injury to the internal coat and in that way predisposes to 
coagulation. 

Diminution of the blood- flow may result not only from 
cardiac disturbances but also from conditions causing a 
decrease in the lumen of the vessel. As the current slows 
the leukocytes tend to adhere to the wall of the vessel, blood- 
plates make their appearance, and fibrin is deposited. The 
nutrition of the endotheHum suffers, changes take place in 
the wall, and another factor in thrombosis then arises. The 
appearance of a thrombus depends upon the number of 
red corpuscles contained within it, and that rests upon the 
varying rapidity of the blood- current at the time of forma- 
tion. It is generally made up of superimposed layers of 
fibrin. 

If the blood were passing through the vessel with consid- 
erable velocity, the thrombus would be grayish-white in color, 
and on section would show well-marked lamination. This 
is called a ii'Jiite thrombus. 

If the blood were moving less raj^idly, varying numbers 
of red cells would be entangled in the fibrin and the color 
would be brown or grayish- red, giving rise to a mixed 
tlirombus. 

If it is formed in a short time from blood that is barely 
moving, a red thrombus will result. 

A true thrombus differs from a post-mortem clot in that 
the latter is moister, is never adherent to the vessel wall, 
and never laminated. It may show a division into a pale 
and dark portion as a result of the coagulation taking place 
after the heavier red corpuscles have sunk. 



44 A MANUAL OF PATHOLOGY 

Thrombi may be classified according to their etiology as: 

1. Injections — those depending upon the entrance of 
bacteria into the circulation. 

2. Mechanical — foreign bodies free from organisms. 
According to their period of formation as : 

1. Primary or initial thrombi. 

2. Secondary or consequential, depending upon a pre- 
existing thrombus and usually extending to the first collat- 
eral branch of the blood-vessel. 

According to their morphology as : 

1. Central, occluding, or obstructing — formed by the coag- 
ulation of the entire mass of blood contained within a certain 
portion of the vessel. 

2. Parietal — when attached to the wall of the vessel but 
not completely obstructing it. 

3. Valvular — parietal thrombi that have become par- 
tially detached. 

4. Channeled or tunneled — ones in which there still exists 
a lumen through which the blood can pass. May be the 
result of secondary changes in old thrombi. 

5. Ball — thrombi that lie free within the cavities of the 
heart, usually in the auricles. 

6. Polypoid— boll thrombi with pedicles. 
Metamorphoses oj Thrombi. — The ultimate fate of thrombi 

depends upon whether they are septic or aseptic. If septic, 
they must undergo disintegration. If aseptic, they may 
undergo organization — a condition that is not a transforma- 
tion into, but is a replacement by, connective tissue. 

They may undergo a central liquefaction or softening. 
The interior is broken down, blood-pigment set free, and 
leukocytes in varying numbers are present. 

Calcification, particularly of small thrombi, giving rise to 
either arterioliths or phleboliths, according to whether they 
occur in arteries or in veins. 

The connective tissue that replaces the thrombi will grad- 
ually undergo contraction until only a hard fibrous mass 
remains ; the original lesion becoming converted into a scar. 

The new tissue is derived from the endothelium of the 



CIRCULATORY DISORDERS 



45 



blood-vessel. As it forms, the thrombus undergoes absorp- 
tion and breaks down into a mass, the granules of which 
are removed by the leukocytes. 

If the thrombi contain living organisms they will be car- 



^- 




Fig. 3. — Organized and Partly Canalized Thrombus of the Bra- 
chial Artery (Hcmat., Orcein). X 32 (Durck). 
I, Adventitia; 2, tunica media; 3, organized thrombus — i.e., replaced 
l)y connective tissue; 4, newly formed and in part dilated vessels within 
the thrombus; 5, disintegrated remains of the old thrombus. 



ried through the circulation and give rise to metastatic 
abscesses in various parts of the body. 

The broken-down portions may become lodged in small 
vessels, and, acting as emboli, give rise to the condition 
known as embohsm. 



46 A MANUAL OF PATHOLOGY 

Embolism is the intravascular obstruction from the lodg- 
ment of a foreign body. The circulating body is known as 
an embolus. 

The most common variety of embolus is a dislodged 
portion of a thrombus, particularly those that occur upon the 
valves of the heart. Other emboli may be formed by cells 
of malignant tumors, masses of bacteria, blood parasites, 
particles of fat, and air. 




o 





















'^ 00 



(9' 



Fig. 4. — Infectious Embolism of the Kidney Following Endocardi- 
tis AND showing Groups of Staphylococci in a Glomerulus 
(Diirck). 

The varieties of emboH are: (i) Simple, mechanical, or 
aseptic; (2) specific, injections, or septic. 

The latter is the more severe, as in it suppurative condi- 
tions are associated with the m.echanical. 

Retrograde embolism occurs when, as in whooping-cough, 
the intrathoracic pressure is increased. An embolus in the 
inferior vena cava may be carried in a direction opposite to 



CIRCULATORY DISORDERS 47 

the blood- current and be thus conveyed into the Hver through 
the hepatic vein. 

Crossed or paradoxical emboHsm occurs when the fora- 
men ovale remains patulous. In this condition an embolus 
may pass directly from the venous to the general circula- 
tion without going through the pulmonary vessels. 

The results of embohsm are numerous: 

1. Inflammation of the vessel walls is usually the result 
of the lodgment of the embolus, particularly if it is of the 
infectious type. 

2. Thrombosis as a consequence of the stoppage of the 
flow of blood by the foreign body. The resulting thrombus 
may be much more extensive than the primary embolus. 

3. Gangrene may result if the main artery of a part has 
been obstructed and the collateral circulation has been in- 
sufficient or unable to supply the demands. 

4. Necrosis when the nutrition of a comparatively small 
area is cut off. Occurs chiefly in the internal organs. 

5. Atrophy may follow if the blood-supply is not quite 
enough for the normal demands, but is yet sufficient to pre- 
vent actual death of the tissues. 

6. Aneurysmal dilatation, especially in the brain, sometimes 
results. 

7. Infarction. 

Infarction. — x\n infarct is the area of degeneration and 
inflammation producecl by embolism in an end-artery. The 
act of obstruction constitutes infarction. 

Infarcts occur only in the so-called end-arteries of Cohn- 
heim — those that terminate in veins or capillaries without 
anastomosis with an artery. They are found particularly 
in the kidney, spleen, base of the brain, and lungs, and some- 
times in the heart. 

The varieties of infarcts are: (i) Anetnic or white; (2) 
hemorrhagic or red. 

The anemic occur more commonly in solid organs, such 
as the kidney; the hemorrhagic in organs whose structure 
is loose, as the lungs. The spleen may be the seat of either 
form. 



48 A MANUAL OF PATHOLOGY 

An anemic infarct is one in which there is an absence of 
blood. 

A hemorrhagic one is where the obstructed area is full of 
blood. It may be the result of a back How of blood from 
the veins (Cohnheim's theory), or from free capillary anas- 
tomosis. The latter would be particularly apt to occur when 
the local or general blood-pressure was previously elevated; 
or when the lodgment of an embolus caused a reflex con- 
traction of the surrounding vessels and thus brought 
about an overflow of blood into the occluded area through 

the capillary anastomoses. 
Another theory is that the 
blood does not escape until 
there has been some degene- 
ration of the vessel walls. 

When the l^lood is cut off a 
conical shaped area of tissue is 
deprived of nutrition. As a 
result, necrosis soon starts in. 
The apex of this area is di- 
rected toward the interior of 
the organ, the base to the ex- 
FiG^s.-lRREGULARLY PYRAMID- ^cmal surfacc. The base will 
AL-SHAPED Anemic Infarct be swollen and project above 
IN THE Spleen, with Soft- the surface of the surrounding: 

ENING ABOUT THE Apex, DUE fic-c-iipc 

TO PImbolism OF THE Splenic i^issues. 

Artery (Hektoen). The infarct is, as a rule, 

firmer than the rest of the or- 
gan, except when it occurs in the central nervous system, 
where it is usually softer; the firmness depending upon the 
amount of coagulable material present. 

Infarctions of the lung are unusual, as in that organ the 
capillaries are comparatively large, and the anastomosis 
between the pulmonary and bronchial arteries may be suffi- 
cient to prevent necrosis. To have infarcts occur within the 
lung that organ must have been the seat of previous disease. 
Results. — Infarction is always accompanied by necrosis 
and fatty degeneration, (i) The tissue may be restored 




CIRCULATORY DISORDERS 49 

by absorption and by collateral circulation. (2) It may be 
replaced by connective tissue with the formation of a scar. 
(3) It may become encapsulated. (4) Very rarely an in- 
farct may undergo liquefaction necrosis with cyst formation, 
particularly in the brain. 

Edema or dropsy is an excess of a clear watery fluid 
within the tissues between the cells. This fluid differs from 
the blood-plasma in that it has less albumin, is of a lower 
specific gravity, is rich in salts, but does not coagulate spon- 
taneously, as it contains very little fibrin. This is called a 
transudate to distinguish it from the fluid present in inflam- 
mations, the latter being called an exudate. 

It is brought about by a disturbed balance between the 
transudation from the blood-vessels and the absorption by 
the lymphatics. It may be caused by : 

1. An increased transudation of fluid from the blood, as 
in active and passive hyperemia, the latter being the most 
common form. 

2. Changes in the quality of the blood. 

3. Increased permeability of the blood-vessel walls. 

4. Disturbances in the pressure outside of the vessels. 

5. Obstruction oj the lymphatic circulation. 

The most important cause is the alteration of the blood- 
vessel walls. This condition alone may give rise to marked 
edema. The changes are dcjx^ndent upon lack of nutrition. 

As a general rule several of the above factors act in com- 
bination. 

Angioneurotic edema is a localized form due to disturbed 
innervation. 

Edema ex vacuo is that which occurs when an organ does 
not completely fill its cavity and the remaining space becomes 
filled with fluid. Usually occurs in the cranial cavity and 
in the spinal canal. 

According to the seat of the edema, s})ecial terms are 
employed. 

When the subcutaneous tissues are generally involved, it 
is known as anasarca. Ascites refers to a collection of fluid 
within the abdominal cavity. 
4 



50 A MANUAL OF PATHOLOGY 

Hydrothorax, a collection within the pleural cavities. 

Hydro pericardium, when within the pericardium. 

Hydrocephalus, fluid within the ventricles of the brain. 

Hydrocele, when within the tunica vaginalis testis. 

The common cHnical causes are: (i) Cardiac insufiiciency, 
the edema usually first noticed about the ankles. (2) Kid- 
ney disease, first seen about the eyes. (3) Cirrhosis of the 
liver, accompanied by ascites. (4) Anemia and cachexia. 
(5) Pressure upon the veins or lymphatics. 

Under the microscope the cells of the involved tissues will 
appear more or less widely separated and in some instances 
may be vacuolated. 

Interstitial emphysema is an infiltration of the tissues by 
gas. It is usually the result of some injury involving the res- 
piratory tract. It may be due to the presence of some gas- 
producing bacteria, such as the bacillus of malignant edema 
or the B. aerogenes capsulatus. It a is comparatively rare 
condition. 



CHAPTER V 

RETROGRESSIVE PROCESSES 

Aplasia signifies a total failure of development of a part. 
Hypoplasia is an incomplete development. 

ATROPHY 

Atrophy refers to a decrease in the size and in the func- 
tional activity of a part. It may be general or local. 

In general atrophy the entire body wastes, a condition 
known as emaciation. It may be the result of lack of food, 
of starvation, or of disturbances of trophic influences with 
disorders of metabohsm. 

In local atrophy certain portions undergo changes which 
may be either simple or degenerative^ or numerical^ as the 
latter is sometimes called. 

In the simple variety the individual cells undergo a de- 
crease in size. 

In the degenerative the number of cells is reduced as a 
result of disease. This is not considered a condition of 
true atrophy. 

Atrophy may be brought about by there being no longer 
a demand made upon the part. Through lack of use the 
cells become smaller. 

Old age is often accompanied by atrophy; is seen particu- 
larly in the sexual organs. 

Pressure is one of the commonest causes; occurs as a 
result of tight lacing, etc. 

Interjerence with the blood -sup ply on account of the part 
not being supplied with a proper amount of nutrition. 

Disturbances oj the trophic junctions, as in poliomyelitis. 

The atrophied part will be smaller than normal, and fre- 
quently very irregular, causing elevations and depressions. 

51 



52 A MANUAL OF PATHOLOGY 

Microscopically the cells will be reduced in size, more or 
less degenerated, and frequently pigmented. The latter 
condition occurs commonly in the heart and is known as 
brown atrophy. 

DEGENERATIONS 

Degenerations of cells can be divided into two forms: 

1. Infillrallojis, in which abnormal substances are deposited 
within the cells. 

2. AI clamor piloses, in which the protoplasm of the cell is 
transformed into abnormal substances. 

The changes in the cHl may also be cither quantitative, as 
when a normal substance is present in an abnormal amount; 
or qualitative, when there is an abnormal substance present. 

Necrobiosis refers to the molecular or cellular death of a 
part. 

Parenchymatous Degeneration or Cloudy Swell- 
ing. — In it the protojjlasm of the cells contains an increased 
amount of proteid substances. It accompanies very slight 
disturbances of nutrition, such as occur in inflammation; 
is found in all infectious diseases and intoxications, possi- 
bly as a result of increased bodily temperature, most likely 
as a result of disturbances of metabolism. 

Although all the cells of the body, both glandular and 
stroma, may undergo this change, they are not equally 
affected, the glandular ones being more liable to injury. 
The secreting cells have as their function the removal of 
certain substances from the body. If the blood contains 
injurious materials these cells will naturally be the first 
affected, as they are the more intimately concerned. 

This degeneration may follow extensive superficial burns, 
probably as a result of the action of the poisonous sub- 
stances absorbed. 

Microscopically the individual cells will be swollen and 
larger, more granular, and more opaque than normal on 
account of the presence of minute granules. These latter 
are insoluble in alcohol and ether, but are dissolved by alka- 
hes and weak acetic acid. 



RETROGRESSIVE PROCESSES 



53 



The function of the cell is more or less disturbed, but com- 
plete recovery frequently occurs. If, however, the cause 
persists fatty metamorphosis results. 

Fatty infiltration is the deposit of fat within the cell 
or intercellular tissues. May be general or local. It may 
occur in cells that normally contain no fat, or else appear in 
excess in cells that do contain it. 




Fig. 6. — Cloudy Swelling of Renal Epithelium. X 800 (Ziegler). 
a, Normal epithelium; h, beginning cloudy swelling; c, marked degenera- 
tion; (/, des(]uamated degenerated epithelium. 



The fat contained within the cells is made up of neutral 
palmitin, olein, and stearin. 

Fatty infiltration may be heredilary, as obesity in succes- 
sive generations; may result from excessive nutrition^ par- 
ticularly if combined with lack oj exercise. 

The use of alcohol^ especially in the form of malt liquors. 

Anemia^ on account of the insufficient oxygenation of 
the tissues. 



54 



A MANUAL OF PATHOLOGY 



In certain cachectic conditions, as in phthisis; where the 
liver is frequently filled with fat. 

The most common seats are the subcutaneous and sub- 
serous tissues, the omentum and the mesentery, in the liver, 
heart, kidney, and between the muscle-fibers. 







Fig. 7. — Fatty Infiltkatiun of the T.iver (McFarland). 
a, Periportal connective tissue; b, fat drops in liver cells. 



Certain other regions, such as the subcutaneous tissue of 
the penis, nose, ears, lips, and eyehds, are never involved. 

An organ the seat of fatty infiltration is larger, paler, 
mottled, streaked, or diffusely yellow, softer, more friable 
and greasy on section. 

Under the microscope the fat may be found either inside 



RETROGRESSIVE PROCESSES 55 

or outside of the cells. If outside, it is most marked along the 
fibrous bands. 

Inside the cell, particularly the glandular variety, the fat 
occurs in droplets which tend to enlarge and coalesce. 
The nucleus is displaced, giving the "signet-ring" appear- 
ance, or obscured; is seldom destroyed. The cell wall 
remains intact. 

The tests for fat are sudan III, which stains it scarlet, or 
a I per cent, solution of osmic acid, which stains black. It 
is soluble in alcohol, ether, and xylol; insoluble in water, 
acids, and alkalies. 

Adipocere refers to the transformation of the fats into a 
wax-like substance most common in bodies that have been 
buried in damp earth. 

Fatty metamorphosis is a conversion of the cell pro- 
toplasm into fat. 

Generally speaking, the causes of cloudy swelhng will 
bring about fatty degeneration if they are severe enough or 
act for a sufficiently long time. It occurs in senility, par- 
ticularly when associated with marked arteriosclerosis, in 
anemia, either as a result of hemorrhage or in diseases such 
as leukemia and pernicious anemia. The condition is 
probably more widespread in the latter than in any other 
disease. Occurs also in long-continued and high fever. 

The most important substances causing the metamor- 
phosis are the poisons, as the metallic salts, chloroform, coal- 
tar products, etc.; those formed by micro-organismal 
activity, as in yellow fever. 

Organs undergoing this change are generally smaller, 
paler, and yellowish, soft, flabby, and easily friable; may 
undergo caseation. 

The liver in yellow fever is a typical example. 

Microscopically the cell protoplasm contains a large num- 
ber of minute droplets that rarely coalesce. The nucleus 
is soon involved and ultimately is destroyed. The entire 
cell may break down into a fatty granular mass, sometimes 
called a "compound granule cell. " 

To distinguish between fatty metamorphosis and fatty 
infiltration is frequently not only dift'icult but impossible, 



56 A MANUAL OF PATHOLOGY 

especially so in the liver. The droplets may coalesce in 
metamorphosis and remain separate in infiltration. 

Crystals of margarin and the notched rhombic plates of 
cholesterin are frequently found in the fatty areas. 

Hyaline metamorphosis is a conversion of cells and 
intercellular substance into hyaline material. 

The cells of the connective tissue are most frequently 
involved, but epithehal and muscle cells may be affected. 

The hyaline material occurs in the form of granules and 










Fig. 8. — Hyaline Degeneration of an Ovarian Capillary. Oc. 2; 
ob. 9 (McFarland). 



is glistening waxy, and with Van Gieson's method stains 
intensely red. 

It is at times scarcely distinguishable from amyloid met- 
amorphosis. 

It is found as a result of infectious diseases, septic pro- 
cesses, in chronic intoxications, such as lead poisoning, and in 
new growths. Its formation is probably dependent upon 
some malnutrition of the tissues. Generally this form of 



RETROGRESSIVE PROCESSES 57 

degeneration is not sufficiently extensive to be recognized 
by the naked eye. 

The most common site is in the endothehal and subendo- 
thehal tissues of the blood-vessels. The lumen will be 
narrowed or obliterated according to the extent of the thick- 
ening of the wall. 

It also frequently occurs in the interstitial tissues, as 
between the renal tubules, between muscle-fibers, hepatic 










^:^i^. 






' v*'' 'fyi'':,: z**:^ 



^•.,::^^^- ,, -^-- '=••■ '-...m^^^i&H^ 

Fig. 9. — Hyaline Decenekation of the Reticulum of a Lymph- 
gland IN Tuberculosis. X 280 (Durck). 
Among the lymphocytes are seen single reticular fibers, which are 
greatly thickened and transformed into shining, homogeneous, nonnu- 
cleated bars (i). 

cells, and in the reticulum of lymph-nodes (Recklinghausen's 
degeneration). A third site is within the cells, particularly 
those of mesodermic origin. 

It is either formed within the cell or, being formed else- 
where, has been brought to and deposited within the cell. 

Mucoid or myxomatous metamorphosis is the con- 
version of cells and intercellular substances into mucin. 



58 A MANUAL OF PATHOLOGY 

Mucin is insoluble in water but will absorb it; is solu- 
ble in alkaline solutions but is precipitated by weak acetic 
acid. 

Either epithelial cells or the intercellular substances may 
undergo mucoid change. The latter is the more truly a 
metamorphosis. 

It occurs in epithehal cells in all forms of catarrhal in- 
flammation, in the cells of epithelial cysts, and in some car- 
cinomata. 

It is found in the interstitial tissues in both epithelial 
and connective-tissue growths, in some inflammatory condi- 
tions, and in myxedema. 

The mucous membranes will be covered by a coat of thick, 
stringy, and viscid exudate. The underlying tissues may 
or may not show congestion. 

Connective tissues will be more or less soft, slightly sw^ollen, 
and will tear easily. If the condition is very much 
localized, cysts filled with mucin may be found. Three 
substances closely related are included under the heading 
of myxomatous metamorphosis: mucin, pscudomucin, and 
paramucin, each one differing slightly from the others in its 
reaction. 

The typical mucoid cell is the so-called "goblet-cell" 
that is found in the large intestine. 

The mucoid change looks under the microscope very much 
like edema. The cells are widely separated and the struc- 
ture of the tissue is poorly defined. The cells frequently 
stain poorly and degenerate. 

Colloid metamorphosis is the transformation of the 
cell into a thick, sticky substance known as colloid. It is 
found only in epithelial cells. It is not precipitated by acetic 
acid or by alcohol, nor does it swell in water. It usually 
stains orange color with van Gieson. 

It is normally found in the acini of the thyroid gland and 
in the pituitary body. It is frequently found in parova- 
rian cysts, in goiter, in the tubules of the kidney, in chronic 
nephritis, and in the prostate gland. 

In cysts the colloid material is generally contained in 



RETROGRESSIVE PROCESSES 



59 



many small cavities, giving rise to a honeycomb appearance. 
It may be transparent, yellowish, bluish, or chocolate color, 
according to other substances present. 

Amyloid metamorphosis is a degeneration of the con- 
nective tissues into an abnormal substance giving an amy- 
loid reaction. The origin of this material is obscure. It 
may be formed in loco or else brought to the tissue from 
some other part of the body. It does not exist as such in 









If -^x 







Fig. io. — Colloid Deoexeuation of the Thyroid Gland, showing 
Masses of Colloid Matter in the Gland Acini (Karg and 
Schmorl). 



the blood, but is very probably derived from substances con- 
tained in that fluid. Some believe that the leukocytes, others 
that the erythrocytes, are the cells from which it is derived. 

It is frequently called waxy, lardaceotis, or ^' barony ^^ 
disease; is found in the intercellular portions of the con- 
nective tissues and not in secreting cells. 

It is found as a result of long-continued suppuration and 
ulceration, such as occur in diseases of the bone, chronic 
tuberculosis, syphilis, leukemia, and dysentery. 



6o A MANUAL OF PATHOLOGY 

The organs most commonly affected are the kidney, Hver 
and spleen, the larger blood-vessels, the mucous mem- 
brane of the intestines, the lymph-nodes, and the heart. 

The involved organs are generally pale, larger and firmer 
than normal, and with rounded edges. The cut sur- 
face is smooth, ghstening, and transparent, either diffuse or 
localized. The usual sites of the degeneration are the walls 




Fig. II. — Amyloid 1 )i,(.t:\f,r.\tt()X of the Liver. X 98. Hematox- 
ylin-eosin (Diirck). 
I, Central vein. Portal capillaries surrounded by homogeneous masses 
and bands; the epithelial lining distinct. Columns of liver cells compressed 
to narrow, atrophic strips. 



of the capillaries, in the intima and media, the adventitia 
being rarely affected. 

In the kidney the capillaries of the glomeruli are first 
attacked, converting the bodies into waxy, homogeneous 
masses; finally the connective tissue may be involved. 

In the liver the metamorphosis is deposited between the 
periportal connective tissue and the central vein. In the 



RETROGRESSIVE PROCESSES 6 1 

spleen it may give rise to the ''sago spleen," a condition 
which is brought about by the formation of amyloid mate- 
rial in the Malpighian bodies. Later on, the organ may 
become very extensively involved. In some cases the ves- 
sels in the trabecular of the organ may be the seat of the 
metamorphosis. 

When amyloid material has been once deposited it is 
practically never removed. It is insoluble in water, alcohol, 
ether, dilute acids, alkahcs, etc. Unless special staining 
methods arc employed it frequently cannot be distinguished 
from hyaline degeneration. 

When the affected tissue is placed in Lugol's solution 
(iodin I, potassium iodid 2, water ico) the amyloid sub- 
stance becomes a mahogany brown. If stained in 5 per cent, 
aqueous gentian-violet the amyloid will appear pink, the 
normal tissues blue. 

If after staining in iodin weak sulphuric acid is added, 
the amyloid will turn blue. 

Corpora amyiacea or amyloid bodies are found in the 
prostate gland, in lymphatic nodes, and in the central ner- 
vous system. They are concentrically striated like a starch 
granule, and although in their reaction they may resem- 
ble starch and amyloid, they arc probably neither. 

Glycogenic infiltration is a deposit of glycogen within 
the cells. It is found normally in small amount throughout 
the body except in the mammary glands and central nervous 
system. 

It is greatest in amount in the cells of the hver, in vol- 
untary muscles, and in the kidneys; is also present nor- 
mally in the blood, both in the plasma and in the cells, 
particularly the polymorphonucelear leukocytes. It is also 
commonly found in malignant tumors of mesodermic ori- 
gin (sarcomata). 

The origin of the glycogen is not clear; it is a carbo- 
hydrate, but seems to be derived from proteid and carbo- 
hydrate substances. Glycogen is most frequently found in 
the condition known as diabetes. 

Tissues containing large amounts of glycogen may have 



62 A MANUAL OF PATHOLOGY 

a distinct hyaline appearance. The reactions, however, 
differ, as it is soluble in water, but not in alcohol, ether, or 
xylol; is colored a brownish- red on the addition of tinc- 
ture of iodin i part, absolute alcohol 4 parts. The brown 
is not changed to blue on the addition of sulphuric acid. 

Microscopically glycogen occurs in the cells in clear, 
colorless droplets, usually near the nuclei. 

Serous or edematous infiltration is a condition of dropsy 
of the cells. All kinds of cells may be involved, but it is 
most common in the epithelial. It is an absorption of an 
excess of plasma by the cells. 

It may accompany general dropsy or result from inflam- 
mation; is also found in tumors. 

The part involved is usually enlarged, spongy, and edem- 
atous. 

The cells arc distended and filled with large and small 
vacuoles in the protoi)lasm and at times within the nucleus. 

Pigmentary infiltration is the deposit of pigment within 
the tissues. 

According to their origin, pigments may be divided into 
four classes: 

1. Those derived from outside of the body. 

2. Those formed from hemoglobin and its derivatives, 
the hematogenous pigments. 

3. The hepatogenous or biliary pigments. 

4. Metabolic pigment; that resulting from cellular activ- 
ity w^ithin the body is known as melanin. 

The hematogenous ]:)igments are three — hemoglobin, hemo- 
siderin, and hematoidin. 

Hemoglobin is dark red in color, amorphous, contains 
iron, and is soluble in alcohol, ether, and chloroform. It 
is recognized chemically by the addition to the suspected 
fluid of a few drops of a fresh tincture of guaiac and then 
followed by an ethereal solution of hydrogen dioxid. The 
mixture, which is at first milky white, turns a deep blue. 

If the dried blood is dissolved in normal salt solution, then 
warmed and evaporated, glacial acetic acid added and 
warmed, small reddish-brown rhombic plates of hemin appear. 



RETROGRESSIVE PROCESSES 63 

When brought in contact with sulphureted hydrogen, 
hemoglobin combines and forms ferrous sulphid, which is 
black. 

Hemoglobin is set free from the erythrocytes through 
hemolysis, either within the vessels or when the blood has 
escaped into the tissues. The surrounding structures will 
be diffusely stained. This is commonly seen postmortem, par- 
ticularly in those parts of the liver that are in contact with 
the intestines. When it is set free within the vessels during 
life, it may be deposited within the lymph-nodes, spleen, 
and kidney, forming pigment metastases. 

Hemosiderin is yellowish or brownish in color, amor- 
phous, contains iron, and is insoluble in water, alkahes, 
alcohol, ether, xylol, and chloroform. 

On the addition of potassium fcrrocyanid and weak 
hydrochloric acid it turns blue (Prussian blue reaction). 

It occurs in the blood, in cells and intercellular tissues, 
as a consequence of recent hemorrhages; apparently re- 
sults from the slow destruction of the erythrocytes. 

The granules are taken up by the phagocytes and may 
be finally removed by them. Cells filled with the granules 
are frequently found in the sputum in cases of chronic con- 
gestion of the lungs. 

Heniatoidin is a reddish-brown pigment, found in the 
form of rhombic crystals; does not contain iron, is insolu- 
ble in water, alcohol, or ether, but is soluble in chloroform. 
It is found at the seat of old hemorrhages, and is generally 
considered a later form of hemosiderin. 

The causes of hematogenous pigmentation can be divided 
into local and general. 

Local. — Hyperemia, venous stasis, inflammation, hemor- 
rhage. 

General. — Hemolysis resulting from animal poisons, bac- 
terial toxins, chemicals. Action of parasites, as in the 
destruction of the red cells in malaria. 

Hepatogenous pigmentation is due to the presence of pig- 
ments derived from the bile, bilirubin, which is similar to 
hematoidin, and its oxidation product, biliverdin. The biH- 



64 A MANUAL OF PATHOLOGY 

rubin is formed by the hepatic cells from hemoglobin. It 
is soluble and consequently is taken up by the blood and 
carried throughout the body, giving rise to the discolora- 
tion known as icterus or jaundice. Both cells and inter- 
cellular substances may be diffusely stained, or if the con- 
dition is of long standing, greenish-yellow crystals or granules 
may be found. 

The fluids of the body will also be discolored. 

The presence of these pigments can be recognized by 
Gmelin^s test. Fuming nitric acid will give a play of colors 
at the point of contact. 

This condition may be caused by (i) obstruction to the 
outflow of bile through the ducts, obstructive jaundice; (2) 
possibly through excessive bile formation resulting from 
hemolysis, hematogenous jaundice; (3) hepatic disorders, 
as acute yellow atrophy of the liver. 

Metabolic pigmentation or melanosis is a discoloration of 
the tissues through the formation of melanin by the cells. 

The tissues are colored yellow, brown, or black. 

Under the microscope melanin occurs as dark granules 
in the cells and intercellular tissues. 

Its chemistry is not well known. It contains sulphur but 
no iron, is insoluble in water, alcohol, and ether, but soluble 
in boiling alcohol, acids, and alkalies. 

It is found commonly in the melanotic sarcoma. It gener- 
ally tends to destroy the cells in which it is contained, and 
for some reason such tumors are generally more rapidly 
metastatic and fatal than the non-pigmcntcd forms. 

In Addison^ s disease there is a general bronzing or mel- 
anosis of the skin. In many cases this condition seems to 
follow extensive disease of the adrenals. 

In malaria some of the hemoglobin is transformed by the 
parasite into melanin. 

Certain muscular degenerations, as in "brown atrophy" 
of the heart. Is questionable whether such granules are 
true melanin. Various skin afjections, as freckles, or len- 
tigo, chloasma, and also in pigmented moles. 

Extraneous pigmentation results from the introduction 



RETROGRESSIVE PROCESSES 



65 



,1 



I: 



;< 



S 



i 



I 



of coloring matters into the body from the outside. The 
tissues most commonly affected are those of the lungs, giv- 
ing rise to the condition known as pneumonokoniosis . 

Anthracosis, or the deposition of coal-dust, is the most 
frequent, the lung being colored more or less black accord- 
ing to the amount present. 

Siderosis results from the inhalation of fine particles of iron. 

Chalicosis, caused by 
the presence of Hme in 
the lungs. 

Argyria is a bluish- 
gray discoloration of the 
skin resulting from the 
long-continued use, in- 
ternally, of nitrate of sil- 
ver. 

Talloo marks following 
the introduction of insolu- 
ble coloring substances 
into the skin. 

Calcareous infiltra- 
tion or calcification re- 
fers to the deposit of 
earthy salts within the tis- 
sues. Usually it is either 
in the form of the phos- 
phate or carbonate of 
calcium, but oxalates arc 
generally present as well 
as magnesium salts. 

This process occurs 
only in those tissues that 

are either completely destroyed or else undergoing degenera- 
tion as a result of imperfect nutrition. 

It is commonly seen in the fibrous framework, but may 

be found within the cells as well. The favorite site is in 

the connective tissues that have a poor blood-supply, such 

as cartilage, the walls of blood-vessels, also in old inflam- 

5 



Fig. 



12. — Brown Atrophy of thp: 
Heart-muscle in Longitudinal 
Section (Durck). 



66 A MANUAL OF PATHOLOGY 

matory areas, in regions of degeneration such as infarcts, 
around foreign bodies, and in tumors. Is sometimes seen in 
the ganghonic nerve-cells, in the "pearls" of epitheHomata, 
and in the tumors of the nervous system called psammoma, 
which are made up of masses of salts deposited in the tis- 
sues. The most common seat is probably in the arterial 
system. It is often the sequel of a senile atrophy of the 




. i^^-y-- ■i'*'^; 



t^. 



'»^{f&. 







b"- . ^^.«:v>.. 



Fig. 13. — Anthracosis of the Lung. X 100 (Durck). 
The lung tissue is very much indurated as the result of newly formed 
connective tissue in which arc embedded star-shaped masses of fine, granu- 
lar, blackish pigment of inhaled coal particles. 

elastic tissue of the vessel wall along with degeneration of 
the connective tissue and a general fibrosis. 

The valves of the heart frequently undergo calcification, 
as well as the walls of the aorta, the coronary and cerebral 
arteries. 

Microscopically the salts may appear as granules, spicules, 
plates or crystals. 



RETROGRESSIVE PROCESSES 



67 



If within the cellular protoplasm the granules may be 
so numerous as to hide the nucleus. 

The salts are insoluble in ether but give off carbonic acid 
gas when dissolved by hydrochloric acid. They also stain 
very deeply with hematoxylin. 




Fig. 14. — Calcareous Infiltration of the Wall of a Small Artery 
FROM THE Wall of a Gumma of the Liver. Zeiss, Oc. 2; ob. D. 
D. (McFarland). 

In addition to the calcification that has occurred in the media contig- 
uous to the fenestrated elastic layer, there is marked syphilitic endarteritis 
with great reduction in the caliber of the vessel from proliferation of the sub- 
endothelial tissue of the intima. 



The deposition of the salts is probably due to a lack of 
oxygen and an increase of carbon dioxid in the tissues, on 
account of which there is a precipitation of the magnesium 
and calcium carbonates and phosphates. 

Uratic infiltration in the form of sodium biurate occurs 



68 A MANUAL OF PATHOLOGY 

in the cartilages and fibrous tissues in gout. Ordinarily 
the above salt is soluble in the blood, but under certain 
constitutional conditions it is deposited as an insoluble salt. 
These collections are called topJii and are found particularly 
in the joints. 

Necrosis is the death of a part of a living organism. It 
is the death of a part as distinguished from the death of the 
entire body. The causes of necrosis are (i) local injury, 
(2) vascular obstruction, and (3) trophic disturbances. 

Under the local injuries are included those that are me- 
chanical, chemical, thermal, and bacterial. 

Mechanical injuries may cause destruction of the cells 
directly or by interference with the blood-supply. Pres- 
sure of foreign bodies will often bri^g about necrosis. 

Chemical substances such as the acids and alkalies may 
cause destruction of the tissues. 

Thermal injuries, those from extreme heat or cold, will 
more or less quickly destroy the vitality of the cells. 

Bacterial products acting as toxic agents will frequently 
cause necrosis and gangrene. 

If vascular obstruction take place suddenly, the nutri- 
tion will be shut off and necrosis result. 

Trophic disturbances will lessen the resisting power of 
the tissues with subsequent necrosis. This is seen in decu- 
bitus or bedsore that occurs in various forms of spinal disease. 
The perforating ulcer of the foot is another example. 

The cells in the necrosed areas will show different stages 
of disintegration. The cell wall may remain, but the cyto- 
plasm will not stain. There may be complete destruction 
and breaking down of the cell. The granules in the pro- 
toplasm disappear and it in turn becomes cloudy, grad- 
ually breaks up, and vacuoles form. The nucleus may 
lose its staining power or may undergo destruction in one of 
two ways: By karyorrhexis, a breaking down of the chro- 
matin into granules, or by karyolysis, a liquefaction of the 
nuclear constituents. 

Necrosis may be of different varieties. 

Coagulation necrosis is a form of death of the tissues with 



RETROGRESSIVE PROCESSES 69 

a consolidation of the proteid contents. It is a change simi- 
lar to the coagulation of the blood. The fibrin ferment 
present acts upon the fibrin factors and fibrin is formed. 

It is found in thrombi, blood-clots, and interstitial hem- 
orrhages. 

Occurs in various inflammatory exudates, particularly in 
croupous pneumonia and diphtheria, and in infarcts. 

The seat of the necrosis is firmer and paler than normal, 
and dry. Later on it may become softer and discolored as 
a result of disintegration of blood. 

Caseous necrosis is a condition in which the tissues have 
been transformed into a cheese-hke substance. 

It is found only as a sequel to pre-existing coagulation 
necrosis. Is found most commonly in tuberculosis, but 
occurs in tumors and in syphilis. 

Surrounding the area of caseation there is generally a 
zone of coagulation. 

Liquefaction or colliquation 7iecvosis is the death of the 
tissues with liquefaction. It occurs in those tissues that 
contain little proteid substance, especially in anemic in- 
farcts of the brain. The nervous tissue undergoes a soft- 
ening, becomes semifluid, and eventually liquid, remaining 
as a colliquation cyst. 

Gangrene may be of two forms — dry and moist. The 
tissues involved are those that arc exposed cither directly 
or indirectly to the atmosphere. 

Dry gangrene or fnummification is the death of tissues 
with subsequent drying. It occurs particularly in the ex- 
tremities of old people or of those who arc much debilitated. 
Is generally due to some obstruction of the arterial system, 
by a thrombus, an embolus, by disease of the walls, by a 
spasmodic contraction of the vessel or by pressure from the 
outside. It is usually circumscribed, there is very little 
odor, the tissues become almost black and mummify through 
evaporation of the moisture. 

Moist gangrene is the death of living tissues plus an 
infection by bacteria that are capable of producing putre- 
faction. 



70 



A MANUAL OF PATHOLOGY 



It occurs in those parts that are exposed to the air, either 
directly or indirectly. 

It takes place in people who have previously been in good 





L_ 



Fig. 15. — Senile Dry Gangrene of the Lower Extremity, showing 
Line of Demarcation (Hektoen). 



physical condition, usually as the result of extensive venous 
obstruction. 



RETROGRESSIVE PROCESSES 7I 

The part involved undergoes necrosis and afterward 
becomes infected. It becomes greenish-black, gas bulbs 
appear on the skin or in the tissues, and an extremely 
offensive odor develops. 

The cells break down completely, hemorrhage takes place 
as a result of destruction of the blood-vessels, and many 
toxic substances are formed. They resemble the alkaloids 
and may bring about marked disturbances of the organism. 
This form of gangrene may terminate in several ways. 

The dead tissue, sphacelus or slough, gives rise to a zone 
of inflammation, which is known as the line oj demarca- 
tion, at the point of contact with the healthy tissue. At this 
site there is a constantly increasing interval between the dead 
and living tissue. The tissues here break down and form 
the line oj ulceration. It is an attempt of nature to throw 
off the foreign substance and at the same time to form new 
tissue. The process is known as exfoliation. If the necrotic 
tissue cannot be thrown off, as is the case when bone is 
involved, there will probably be a sequestnmi formed. This 
is the result of new bone forming around the dead tissue 
before there has been time for it to exfoliate. 

If the degenerated area cannot be discharged, as when 
the internal organs are involved, it frequently becomes sur- 
rounded by a capsule of connective tissue that protects the 
neighboring parts — process of encapsulation. xA.gain, the 
necrotic tissue may disappear through absorption, may cal- 
cify, or undergo cicatrization or organization. 

Fat necrosis is a peculiar type occurring usually in the 
fat within the abdominal cavity. In nearly all cases it seems 
to be dependent upon some disease of the pancreas. 

It is the result of the splitting of the fat molecule into its 
fatty acid and into glycerin. The fatty acids are deposited 
as crystals and unite with calcium to form salts. 

These areas are generally about the size of a pea, whit- 
ish in color, soft or gritty. A zone of inflammation may or 
may not surround them. 

Death is ther cessation of life. Meaning that all the com- 
ponent parts of the organism cease to live. 



^2 A MANUAL OF PATHOLOGY 

Up to a certain time the cells of the body are able to sup- 
ply all the needs, but eventually the natural term of life is 
reached and the cells gradually fail to support the tissues. 
Such a condition would be termed pJiysiologic death. If, 
however, it follows as a result of diseased i)rocesses, it would 
be pathologic. 

The two, however, cannot be strictly separated, as in old 
age there are always conditions present that are not normal. 

The conditions absolutely necessary for life are a contin- 
uation of circulalion, respiration, and innervation. 

There may be a destruction of certain portions of the 
body without death following, but a cessation of any of the 
above-mentioned functions brings about dissolution. This 
is known as somatic death, and according to which function 
ceased, it is said to have taken place by syncope, asphyxia, 
or coma. 

Molecular death refers to the death of cells. 

Signs oj death are those that indicate that the organism 
has ceased to hve. Cessation of the necessary functions 
may give rise to apparent death, but without other indica- 
tions it cannot be diagnosed with certainty. 

The necessary signs are: 

Algor mortis, a fall of the temperature to that of the sur- 
rounding atmosphere. Following tetanus it may, however, 
be preceded by a distinct rise, continuing for some hours. 

Livores mortis or post-mortem lividity are the discolored 
areas that appear in the dependent portions of the body as a 
result of the dilatation of the blood-vessels. It is often of 
great importance to distinguish this condition from the dis- 
coloration following a blow. In the first the color will 
disappear on pressure, but in a bruise it will remain, as the 
blood is not within the vessels. 

Rigor mortis or post-mortem rigidity is a stiffness due to 
the coagulation of the albumin of the muscles with the for- 
mation of myosinogen. It is first seen in the muscles of 
the neck and jaws, then extends downward, involving the 
entire body. 

It generally comes on within four to twelve hours, but may 



RETROGRESSIVE PROCESSES 73 

appear immediately or be delayed for twenty-four hours. 
At the end of twenty-four to forty-eight hours it usually 
passes off. 

If death has occurred suddenly and the individual is in 
good health, it appears much more quickly than when death 
has taken place slowly. 

Decomposition is the infallible sign. Its appearance 
depends upon the surrounding temperature, taking place 
more quickly in hot weather. It is first noticed as a green- 
ish discoloration of the abdominal wall. Is due to the sul- 
phuretted hydrogen from the intestines acting upon the iron 
contained within the hemoglobin. 

The tissues soften, and there is more or less odor, due 
to the formation of various gases. 

Loss oj elasticity, relaxation oj the sphincter muscles, and 
loss oj transparency oj the cornea and dilatation oj the pupils 
complete the list. 

Apparent death may occur in hysteria, catalepsy, submer- 
sion, cholera, exposure to cold and action of electricity. It 
is detected by the absence of the signs of true death. The 
tissues will appear reddish if a light is held behind them, 
blood will flow from a wound, moisture will collect on a 
mirror held in front of the face, and the muscles will react 
to electricity. 



CHAPTER VI 
INFLAMMATION AND REGENERATION 

Inflammation is the protective reaction of tissues to 
the effects of irritants. 

Etiology. — The causes of inflammation may be divided 
into mechanical^ chemical, and vital, or injections and non- 
injections. 

Traumatism of any nature, such as a blow or the action 
of chemicals, can give rise to an inflammatory reaction and 
be non-infectious. 

The common cause, however, is the action of bacteria 
upon the tissues. The great majority, therefore, of inflam- 
mations are infectious or vital in variety. 

A non-infectious one may become infectious through a 
secondary deposit of bacteria. 

An infectious inflammation is distinguished by the fact 
that it is likely to be progressive, is capable of indefinite 
increase, and may also be transmitted from one individual 
to another. 

Before taking up the pathologic changes of the circula- 
tion it will be necessary to first consider the normal differ- 
ences in the blood-current in arteries, veins, and capillaries. 

In arteries the stream is not constant ; it is regularly inter- 
mittent on account of the rhythmic contractions of the heart. 
It is more rapid than in the veins; the red cells cannot be 
distinguished at the height of systole, but at the end of the 
heart's action the current slows sufficiently for them to be 
seen. The corpuscles occupy the entire lumen, except that 
at the end of the pulse- wave they momentarily withdraw from 
the wall of the blood-vessel. 

In veins the stream is constant and is regular in speed. 

74 



INFLAMMATION AND REGENERATION 



75 



Instead of cells and plasma being uniformly mixed there 
are two zones present : an axial or central zone, composed 
of blood-cells, and a peripheral one, made up of the blood- 
plasma. . In this latter there are occasionally a few leuko- 
cytes but no erythrocytes found. 

In capillaries the current is neither constant nor regu- 
larly intermittent. It is constant during the flow. 

The changes in the circulation in inflammation are as fol- 
lows: 

I. A momentary contraction of the blood-vessel following 
the introduction of the irritant. This is followed bv: 




^ 



.^ 




%scg^ -^ 

Fig. 1 6. — Inflammation of the Mesentery, showing Overfilling of 
THE Blood-vessels, with Emigration of Leukocytes and Dia- 
PEDESis OF Red Corpuscles (Ziegler). 



2. A marked dilatation and relaxation of the vessel with 
at first an increase in the rapidity of, the flow\ The arte- 
rioles are first affected, then the veins and capillaries. 

3- Further increase in dilatation with slowing of the cur- 
rent. Instead of the cells being unrecognizable in the 
arteries they now become distinctly visible. Marked changes 
now occur, particularly in the venous circulation. The plas- 
matic zone, which at first contained only a few leukocytes, 
shows an increase in their number until it is entirely filled 



76 A MANUAL OF PATHOLOGY 

with them. Subsequent to this there takes place an exuda- 
tion of fluid and blood-cells from the vessels. 

Emigration or transmigration oj tJie leukocytes. At first 
the leukocytes adhere but slightly to the walls of the blood- 
vessel, but finally they become closely attached, pass through 
the walls, and become pus cells. 

The leukocytes that escape are of the polymorphonuclear 
variety. They project a small mass of protoplasm through 
the vessel wall. This mass becomes gradually larger till 
the cell lies outside in the surrounding tissues. This pro- 
cess is known as emigration. 

Dia pedes is refers to the escape of red cells from vessels 
whose walls show no lesions. 

At the same time that the cells escape there is an exudation 
or outflow of lymph through the vessel walls. 

As to the emigration of the leukocytes there are various 
theories, but the reasons are not perfectly understood. 
The phenomena can hardly be due to nervous influences, 
as the changes occur too slowly. It is also impossible to 
bring about an inflammatory reaction by stimulating either 
the vaso-constrictors or the vaso-dilators. When the latter 
is done, there is an exudation of plasma but not of cells. 
According to Cohnheim, there is an increased permeability 
of the blood-vessel wall due to structural changes. 

Probably the chief reason is that the ameboid motion of 
the leukocytes is very much stimulated. 

It may also be the result of positive chemotaxis, the attrac- 
tion that certain substances exert upon motile cells. Dead 
tissues and the products of bacterial growth are positively 
chemotactic and their influence may be exerted upon the 
leukocytes while they are still within the blood-vessel. 

Besides the polymorphonuclear leukocyte the round mono- 
nuclear form may also escape, giving rise to the round-cell 
infiltration that is found in acute inflammation and also in 
tuberculosis. 

As a result of the disturbances of the circulation there are 
certain changes in the inflamed part as a whole that are fre- 
quently spoken of as the cardinal symptoms of inflammation : 



INFLAMMATION AND REGENERATION 77 

Pain or dolor, due probably to the pressure exerted upon 
the terminal nerve-filaments. 

Swelling or tumor, due to the increased amount of blood 
present and to the exudate within the tissues. 

Redness or rubor, due also to the hyperemia. 

Heat or calor, the result of two causes, one that more 
blood is brought to the part, the other that the blood moves 
more slowly and heat accumulates. 

Altered junction, or functio lieso, may be added to the 
first four. 

The products oj inflammation are known as inflamma- 
tory exudates. 

A serous exudate is one that is composed of fluid that has 
escaped from the vessels. It contains very few cells and oc- 
curs in very slight inflammations. 

This fluid differs from the non-inflammatory trans- 
udate in containing a greater amount of albumin, and there- 
fore being of a greater specific gravity. 

A fibrinous exudate is one in which there is more or less 
fibrin present. It is formed by the action of fibrin ferment 
acting upon fibrinogen or fibrin-forming substances in the 
presence of calcium salts. This ferment is yielded proba- 
bly to some extent by all the cells of the blood, but particularly 
by the leukocytes. When they die, the ferment is formed 
and the fibrinogen is converted into fibrin. When the leu- 
kocytes arc increased in number, the amount of fibrin is 
usually greater. 

A purulent exudate is one in which there is a preponder- 
ance of escaped leukocytes. It may be found infiltrating 
the tissues or in a circumscribed area known as an abscess. 
This exudate is known as pus. 

Pus is an opaque, yellowish, alkaline fluid. It is made up 
of pus cells, either living or dead polymorphonuclear leu- 
kocytes, and pus serum (liquor puris). Usually some degen- 
erated tissue cells are present. According to whether there 
is blood, serum, or mucus as well, it may be sanious pus, 
sero-pus, and muco-pus. 



78 A MANUAL OF PATHOLOGY 

If the fluid portion is scanty, the pus may be creamy or 
cheesy; or ichorous if the pus is very thin, watery, and acrid. 

An abscess is a circumscribed collection of pus. It is sur- 
rounded by an inflammatory zone incorrectly called a pyo- 
genic membrane. 

An abscess may be hot or cold. The first is the result of 
acute inflammatory changes. The latter is a chronic inflam- 
matory process and the fluid contained within it is not pus 
but is made up of broken-down and degenerated tissues. 

An embolic abscess is one that has followed the lodgment 
of a septic embolus. 

Pyemic or metastatic abscesses are those resulting from 
pyogenic organisms being present in the blood. 

The destruction of tissue that accompanies abscess for- 
mation is in consequence of there being an insufficient 
amount of nutrition and is due also to the dissolving effect 
of digestive enzymes present in the Hquor puris. 

When the broken-down tissue has been cast off there re- 
mains a superficial lesion with loss of substance. This 
area is known as an ulcer. 

A sinus is an inflammatory tract that is open at one end 
from which the exudate can escape. 

A fistula is an inflammatory tract that is open at both ends. 
It is one that joins an internal cavity to the surface. 

A hemorrhagic exudation is one that contains erythro- 
cytes. It generally indicates that there has been a lesion of 
blood-vessels. 

The termination of inflammation depends upon the 
degree of inflammation and the amount of damage done. 
It may occur by resolutioji. This takes place only when 
the inflammation has been shght. The exudate is taken 
up by the lymphatics and returned to the circulation. Any 
degenerated cells will be taken up by the wandering leuko- 
cytes and the tissue will resume its normal condition. 

In suppuration the inflammation has been destructive; 
there is actual loss of tissue, with the formation of pus. 

As pus is formed it is either confined as an abscess or else 
it tends to infiltrate the tissues. In either case the body at- 



INFLAMMATION AND REGENERATION 79 

tempts to get rid of the irritating substance by having it fol- 
low along the least resistant paths and letting it escape 
from the body. This process of extension is known as ''bur- 
rowing"; it results from the increased pressure due to the 
presence of the pus and to the digestive powers of the 
enzymes contained within. 

In some cases the pus may quickly escape to the surface 
of the body and be cast off. It may, however, have to bur- 
row a long distance, as in a psoas abscess, before it can escape. 

Sometimes the pus may gain entrance into one of the cav- 
ities of the body, as the peritoneum or pleura, and give rise 
to inflammatory conditions there. 

According to the cavity involved, the condition has special 
names. Empyema is pus within a pleural cavity; pyoperi- 
cardium when within the pericardial sac; pyosalpinx when 
a Fallopian tube is involved, etc. 

Encapsulation is what takes place when the irritating mate- 
rial cannot be removed from the body. The surround- 
ing tissue cells undergo multiphcation and the substance is 
isolated by the formation of a connective-tissue capsule 
about it. 

Organization is the process of repair by means of which 
the destroyed areas are filled up by connective tissue. It 
is not a case of the transformation of the inflammatory prod- 
ucts into connective tissue, but is a condition of replacing. 
This new formation of connective tissue is known as a cica- 
trix or scar J the process as cicatrization. 

The cells present in the repair of inflammation are derived 
from various sources, and consequently dift'er among them- 
selves. 

The leukocytes that form the greatest numbers are derived 
from the blood and are chiefly of the polymorphonuclear 
variety. 

Lymphocytes both large and small, as well as eosinophilcs 
in small numbers, may also be present. 

Eosinophile cells are actively ameboid and are able to 
escape from the blood-vessels. As a rule, they are not 
present in marked numbers except in certain subacute 



8o A MANUAL OF PATHOLOGY 

or chronic inflammations of the skin or mucous mem- 
branes. 

The plasma cells probably originate within the circulation. 
They are rather large and contain a pale vesicular nucleus 
eccentrically placed and a finely granular basophilic pro- 
toplasm. These cells are usually most numerous in acute 
toxic conditions and are supposed to play some part in the 
formation of connective tissue. 

The mast cells or basophilic leukocytes are large cells 
containing usually a trilobed vesicular nucleus and large 
granules in the cytoplasm. They are most common in 
inflammations of mucous membranes and in the neigh- 
borhood of tumors, especially if they have undergone mu- 
coid changes. 

The fibroblasts or epithelioid cells are formed by the pro- 
liferation of pre-existing connective-tissue cells. 

Giant cells, those containing more than one nucleus, are 
frequently present. The formation of these cells proba- 
bly takes place in one of two ways. If a single cell is not 
sufficiently powerful to remove the offending particle, sev- 
eral may coalesce, and in that way successfully make the 
attack. They may, however, form through a multiplica- 
tion of the nuclei without division of the cytoplasm. 

In the process of repair there is formed what is called 
granulation tissue. In it there is the formation of loops of 
new capillaries derived from the endothelial lining of pre- 
existing blood-vessels. The endothehal cell becomes larger, 
the nucleus divides by mitosis, and two cells are formed. 
These cells continue dividing until a sprout-like process 
extending into the surrounding tissue is formed. Adjoin- 
ing sprouts unite, and although at first solid, finally become 
hollowed out, thus allowing the circulation to be re-estab- 
Hshed. At the same time that this is taking place there is a 
multipHcation of the fixed connective-tissue cells, which 
surround and act as a supporting framework to the loops 
of new-forming capillaries. 

In the proHferation of the connective tissue there is first 
found a small round cell with a round or oval nucleus. 



INFLAMMATION AND REGENERATION 



8i 



As the tissue becomes older the cells tend to elongate and 
become spindle-shaped. At first they are very close together, 
but gradually separate, and the homogeneous intercellular 
substance becomes fibrillar and supports the cells. Those 
cells concerned in the formation of the cicatrix are called 
jihrohlasts. 

In the new-formed tissue there is at first an overproduc- 
tion of cells and blood-vessels, but eventually it becomes 
less vascular and cellular. This is brought about to a great 
extent by the contraction of the cicatrix, which, at first 
reddish and elevated, finally 
becomes pale and depressed. 

According to surgeons, cica- 
trization may take place in 
one of two ways: 

Union by first intention, or 
primary union. In this the 
edges of the wound are closely 
brought together and very 
httle exudate escapes. In this 
narrow space the same pro- 
cesses take place as are seen in 
the formation of granulation 
tissue, but to a much less ex- 
tent. The epitheHal surface 
is replaced by a proliferation 
of the neighboring epithehum. 

Union by second inlention, 
secondary union, or union by 

granulation, takes place when the edges of the wound are 
far apart and there is a large amount of exudate present. 

This process is the same as heahng by first intention, except 
that in it there is suppHed the material to bridge over the gap. 

If an epitheHal surface is affected, the granulation tissue 
is gradually covered by proliferation of adjacent cells. 

Regeneration, although commonly applied to the forma- 
tion of cicatricial tissue, really refers to the power of indi- 
vidual tissues to reproduce their own kind, 
6 




Fig. 17. — FoKMATioN of New 
Blood-vessels, as Seen in 
THE Tail of a Tadpole (Ar- 
nold). 



82 A MANUAL OF PATHOLOGY 

Generally speaking, the more highly specialized the tis- 
sue, the less is its regenerative power. If such tissues are 
destroyed, they are generally replaced by fibrous tissue. A 
cell can give rise in regeneration only to a tissue that has 
the same blastodermic origin. 

The fibrous connective tissue is probably the most active. 

Epithelium of the surface variety is constantly and com- 
pletely regenerating. Whether regeneration takes place in 
the more highly specialized epithelial organs, such as the 
kidney and li\er, is rather improbable. 

Muscular tissue is capable of regeneration to a slight 
degree, but the chief repair after injury to muscle takes place 
within the connective tissues surrounding the fibers. 

Blood-vessels, as is seen in the formation of granulation tis- 
sue, are capable of marked multiplication. The new-formed 
vessels in regeneration are usually only temporary; existing 
only long enough for the tissue to receive its nutrition, then 
disappearing during the contraction of the cicatrix. 

Bone, as is noticed in the repair of fractures, is able to 
undergo complete regeneration. 

Cartilage is incapable of regeneration. In injuries it is 
replaced by fibrous connective tissue. 

Nerve-cells of the highly specialized type, such as ganglion 
cells, cannot regenerate, but the neuroglia or nerve connec- 
tive tissue can. The neurogha differs from the ordinary 
fibrous tissue in that it is derived from the ectodermic layer 
of the blastoderm. 

Varieties of Inflammation. — Inflammation may be, — 

Acute when it arises rapidly, lasts a short time, and de- 
stroys tissue. 

Chronic when arising slowly, lasting a long time, and 
giving rise to the formation of fibrous connective tissue. 

Injectious when caused by some living organism. 

Non-injectious when it does not arise from the action of a 
Hving organism. 

Exudative if the inflammation is characterized by the pres- 
ence of an exudate. According to the variety of the exu- 
date, the inflammation may be as follows : 



INFLAMMATION AND REGENERATION 83 

Serous when the exudate consists of a fluid having few 
cellular contents. 

Fibrinous when particles of fibrin are present in the exu- 
date. 

Purulent when pus cells (leukocytes) arc present in large 
numbers. 

Hemorrhagic when erythrocytes escape in quantity. 

Parenchymatous when the acti\'ely secreting cells of a 
glandular organ are involved. 

Interstitial if the inflammatory process invoh'es the con- 
nective-tissue framework of an organ. 

Catarrhal when limited to mucous membranes. 

Desquajnative if there is a casting off of epithelium in a 
catarrhal inflammation. 

In the early stage the secretion of mucus by the cells 
ceases, the surface becomes dry, and the blood-vessels con- 
gested. Later on, the secretion is increased in amount, 
frequently changed in character, and the congestion of the 
vessels somewhat lessened. 

Vesicular when there are larger and smaller circum- 
scribed elevated areas containing a serous exudate, as in 
bhsters. 

Pustular when the circumscribed elevations contain pus. 

Diphtheritic or croupous when there is a marked coagu- 
lation of fibrin on the surface with the formation of a pseudo- 
membrane in which are found degenerated cells of various 
types — epithelial, leukocytes, and erythrocytes. 

In it there is usually necrosis involving the superficial epi- 
thelium, or going deeper and attacking the submucosa as 
well as the mucosa. 

Ulcerative if accompanied by a loss of superficial sub- 
stance. 

Degenerative when the destruction of tissue is extensive. 

Adhesive when, as the result of the presence of fibrin, 
transformation into fibrous tissue follows and the two op- 
posing surfaces become more or less adherent. It may 
go on to the point where the cavity entirely disappears, 
and is then called ohliterative. 



84 A MANUAL OF PATHOLOGY 

Gangrenous when there has been infection of the tissues 
by putrefying organisms and gangrene is present. 

Phlegmonous when the interstitial tissues become infil- 
trated by pus. 

Productive when the formation of fibrous connective tis- 
sue is prominent. 

Specific when caused by a definite micro-organism. 



CHAPTER VII 
CELL DIVISION 

As a result of the tissue injury in disease repair is brought 
about by cell multiphcation or reproduction. The extent 
of this regeneration depends upon the degree of speciah- 
zation of the tissue. 

The CelL — The adult cell consists primarily of a mass of 
protoplasm or cytoplasm si^rrounded by a limiting mem- 
brane called the cell wall and containing a nucleus within 
which there may be a small body called the nucleolus. 

The cytoplasm, which is a semifluid substance, is divided 
into two portions — the spongio plasm, which consists of a 
very elastic and extensible framework, and the hyaloplasm, 
which is homogeneous and less active. 

Imbedded in the cytoplasm are minute granules known 
as microsomes. These are most numerous toward the cen- 
ter of the cell; the peripheral zone, called exoplasm, not 
containing them. 

Foreign bodies and vacuolations may also be found within 
the cell. 

The arrangement of the constituents of the cytoplasm 
varies at different times. Frequently the spongioplasm is 
arranged as a distinct reticulum. This is, however, not 
permanent, and seems to depend upon the relative propor- 
tion of the hyaloplasm. 

The nucleus is confined by a distinct wall, the nuclear 
membrane, within which is the nuclear substance or karyo- 
mitome. This is divided into a framework of fibrils, the 
nuclear fibril, and an intcrfibrillar substance, the nuclear 
matrix. 

The fibrils consist of a part called chromatin or nuclein 

85 



86 



A MANUAL OF PATHOLOGY 



that has a marked affinity for nuclear stain. This por- 
tion is supported by fine fibrils of linin that do not stain. 

There is also present a semifluid substance known as the 
karyo plasm or nuclear juice. 

The nucleolus lies within the nucleus and consists of a 
substance known as pyrenin. Just what is its function is 
not known. It probably has a distinct purpose during cell 



Vacuoles. 



Chromatin network. 

Linin networl-. 
Ntulear fluid. 

Nuclear membrane. 
Cell-memhrane. 



Exo plasm. 




.St^o)iiiJopIasm. 
Tlyaloplasm. 

Nucleolus. 
Chrnmntin net-knot. 

Centrosome. 
Centrosphere. 



Foreign inclosures. Metaplasm. 

Fig. 1 8. —Diagram of a Cell (Hubcr). 



multiplication, as it disappears during the division of the 
nucleus, but reappears when the new nucleus is formed. 

Another bodv, the centrosome, is also sometimes found. 
It is a smaU, highly refracting body, situated within the 
nucleus. It is surrounded by a clear area called the attrac- 
tion sphere. This body, although it may be found during 
the stage of rest, becomes most noticeable during the stage 



CELL-DIVISION 87 

of division of the nucleus. At that time it divides into two 
and passes to opposite poles of the cells. 

Occasionally a small irregularly spherical body, the para- 
jiucleus, is present in the cytoplasm near the nucleus. Its 
function is not known. 

The relation between the size of the nucleus and that of 
the cell varies greatly. In certain cells, as in the lympho- 
cyte, the nucleus may occupy nearly the entire area. 

The nuclei of the same kind of cells are usually similar 
in shape and size. They may be round, oval, or, as in some 
of the lower animals particularly, irregular. 

A cell may also have one or more nuclei. 

With the exception of the red blood- corpuscles and the 
horny layer of the skin, all cells under normal conditions 
contain nuclei. The absence of a nucleus, therefore, usu- 
ally denotes the loss of cellular activity. 

The functions of cells which distinguish living from 
inorganic tissues can be divided into: 

1. Metabolism, the power of selecting and assimilating 
food, anabolism; and the power of casting off cxcrementi- 
tious matter, cataboHsm. 

2. Growth, the result of assimilation producing an increase 
in the size of the cell. 

3. Irritability, the response of the living cell to external 
influences. 

4. Motion, which may be of three different kinds. There 
is a constant passage of a "circulating albumin" from one 
part of the cell to another. It may be ameboid, so called on 
account of its resemblance to the motion of the ameba. 
It consists of a streaming of the cytoplasm to one point, 
giving rise to prolongations or pseudopodia extending from 
the surface of the cell. 

Ciliary movement is the result of the presence on the sur- 
face of cells of minute, hair-like processes, called cilia. 
These are prolongations and specializations of the proto- 
plasm. The cilia keep up a movement like that of a whip- 
lash. 

5. Reproduction is the multiplication of a cell and may 



8^ A MANUAL OF PATHOLOGY 

take place in one of two ways, either by direct division, 
amitosis, which is not the common method, or by indirect 
division, karyokiuesis, karyoiuitosis, or mitosis. The latter 
is the more usual way. 

In amitosis or direct division there is first noticed a 
slight contraction in the nucleus of the cell. This gradu- 
ally goes on until two new nuclei are formed. During this 
period the cytoplasm begins dividing, and by the time the 
nuclei have migrated to opposite poles, separation has taken 
place and two new cells have formed. 

If the cytoplasm fails to divide, multinuclear or giant cells 
may arise. 

Karyokinesis. — In karyokiuesis, or indirect division, the 
cell goes through a very complicated course of changes of 
the various elements, probably the result of definite metab- 
olic processes. 

The changes can best be considered under four headings : 

I. The Prophase. — The centrosome increases in size, passes 
from the nucleus into the cytoplasm, and divides into two. 

Surrounding each centrosome is a mass of fine radiating 
lines known as the amphiaster. The rays extending from 
one centrosome to another are arranged in spindle form, the 
centrosomes being situated at the apices of the spindles. 
These achromatin rays form the nuclear spindle. 

The nucleus has been enlarging and the chromatin in- 
creasing. These fibrils become tangled and convoluted 
and form the close skein. The fibrils become thicker, less 
convoluted, and arrange themselves in irregular loops, form- 
ing the loose skein. These loops finally separate at their 
peripheral ends and form the chromosomes, V-shaped fibrils 
with their closed ends arranged in a clear space known as 
the polar field. 

During the formation of the skeins the nuclear membrane 
disappears and the chromatin fibrils lie in the cell proto- 
plasm. 

The chromosomes are always present in the same num- 
ber in the same species, varying from 2 to 36 in various ani- 
mals; in man being constantly 16. 



CELL-DIVISION 89 

The arrangement of the fibrils about the polar field con- 
stitutes the mother star or monaster. 

2. The Metaphase. — Each of the chromosomes under- 




a h 

Fig. 19.— Nuclear Changes in Karyokinesis (Hatschek). 
a, Nucleus of spermatoblast of Salamandra maculata, with chromatin 
/threads forming the first suggestion of a coil; h, close coil with disappear- 
( ance of the fuzzy aspect and longitudinal cleavage of the threads. 




Fig. 20. — DiAGRAMM.\Tic Appear- 
ance OF THE Relation of the 
Chromosomes to the Centro- 
somes and Primitive Nucleai^ 
Spindle (Flemming). 




Fig. 21. — Diagrammatic Repre- 
sentation OF THE nuclear 
Spindle and of the Ar- 
rangement OF the Double 
Chromosomes in an Equa- 
torial Plane Prepar.-n.tory 
TO Separ.-\tion. This Stage 
IS Called the Mother Star 
(Flemming). 



goes a longitudinal division into two. These filaments, 
with the closed end advancing, begin to separate, moving 
toward their respective poles or centrosomes. 



90 



A MANUAL OF PATHOLOGY 



3. The anaphase begins with the migration of the chro- 
mosomes. As they move toward the opposite poles the free 





Fig. 22. — Diagrammatic Representation of the Separation of the 
Chromosomes, which are Attracted toward Opposite Poles of 
the Nuclear Spindle, about which They Gather to Form the 
"Daughter Stars" (Flemming). 



ends constitute the equatorial plate. Connecting the ends 
are fine threads of achromatin known as the connecting fihi- 
ments. The chromosomes collect at 
the opposite ends and form the 
daughter stars or diaslers. As this 
occurs there is the beginning of a 
constriction of the protoplasm. 

4. The Telophase. — The constric- 
tion continues until the original cell 
has been completely divided and two 
new ones formed. The chromo- 
somes now undergo in reverse order 
the phases that have been des- 
cribed: the loose skein, the close 
skein, the reappearance of the nu- 
FiG. 2;?.— Segmentation clear membrane and of the nu- 
cleolus, with finally the stage of 




23. — Segmentation 
of the Cytoplasm, 
AND the Chromo- 
somes Equally Di- 
vided, about to 
Form New Nuclei 
IN the New Cells 
(Flemming). 



rest. 



To summarize, the changes are as 



follows : 

Resting mother nucleus. 



CELL-DIVISION Ql 

Prophase. 

Migration and division of centrosome with 

increase of chromatin. 
Close skein. 

Disappearance of nuclear membrane. 
Disappearance of nucleolus. 
Loose skein. 

Separation of skein into chromosomes. 
Appearance of polar field. 
Rearrangement of chromosomes around polar 

field. 
Monaster, or mother star. 
Appearance of nuclear spindle. 
Met a phase. 

Longitudinal division of the chromosomes. 
Anaphase. 

Migration of the divided chromosomes to op- 
posite ends of the cell. 
Formation of the equatorial plate. 
Daughter star, or diaster. 
Telophase. 

Construction of the proto])lasm. 

Daughter skeins undergoing in reverse order the 

above changes. 
The stage of rest. 
In some instances, instead of the cytoplasm dividing when 
cleavage of the nucleus is completed it remains unchanged. 
This may go on until there arc many nuclei imbedded within 
a single mass of cytoplasm. Such formations are know^n as 
giant cells and may be the result of division under unfa- 
vorable circumstances. 

There may be the formation of more than two ccntro- 
somes with a resulting multipolar cell. The equatorial 
segments may split up more than once and the daughter 
cells may divide secondarily. 



CHAPTER VIII 
PROGRESSIVE TISSUE CHANGES 

HYPERTROPHY 

Hypertrophy, generally speaking, means an enlargement 
or overgrowth of any kind. It is usually divided into true and 
]alse hypertrophy or hyperplasia, as the latter is called. 

True hypertrophy is a uniform enlargement of a part, 
dependent upon an increase in size of all of its component 
elements. Accompanying the enlargement there is an in- 
crease in the functional power of the part involved. 

The hypertrophy may be either congenital or acquired. It 
may also be either physiologic or pathologic. The former, 
however, may come under the latter heading when it reaches 
a degree that is not normal to the individual. 

Hypertrophy is called compensatory when one organ takes 
upon itself the amount of work that was primarily carried on 
by two; is known as vicarious when another function 
increases at the expense of one that has been destroyed. 

Etiology. — I. Congenital causes, in which case there are 
marked overgrowths of portions of the body, especially of 
the fingers and toes. 

2. Exercise calls for an increased amount of energy. 
This demand is met by a greater supply of food with a sub- 
sequent increase in size, and is seen in the enlarged muscles 
of a blacksmith, or in a kidney when the other one is diseased 
or absent. These are examples of compensatory hypertrophy. 

3. Nervous influences in some indefinite way play a part 
in hypertrophy, as is seen in the enlargement and increased 
function of the mammary glands during pregnancy. 

4. Disease oj the hypophysis cerebri apparently causes the 
condition called acromegaly, in which the tissues of the face 
and extremities hypertrophy. 

92 



PROGRESSIVE TISSUE CHANGES 93 

Morbid Anatomy. — The part affected is uniformly in- 
creased in size. 

Microscopically hypertrophy may be divided into the 
simple or true and the numerical (hyperplasia). 

In the simple there is an increase in the size of the indi- 
vidual cell. This is seen particularly in the pregnant uterus, 
where at term the unstriped muscle cells may be eleven times 
as long and four times as broad as normal. 

In the numerical variety the cells increase in number, but 
not necessarily in size; may even be smaller than normal. 

Hyperplasia, or false hypertrophy, is a condition in 
which there is an increase in number of the cells with usually 
an asymmetric enlargement of the tissue. 

It occurs most commonly in the fibrous connective tissue. 

Etiology. — I. Irritation is the most common cause, if not 
too severe in character. In that case inflammation with 
consequent degeneration results. 

The irritation may be mechanical, such as results from 
intermittent pressure exerted by tight shoes, or from the 
presence of a foreign body. Chemical irritants, such as alco- 
hol, will bring about an increase in the amount of connective 
tissue, particularly in the liver. In which case there is also 
an increase in the number of bile capillaries. 

2. Nervous influences, such as bring about the condition 
known as pseudo-hypcrtrophic muscular paralysis. In it 
there is not an increase in the muscle itself, but the fat has 
undergone a hyperplasia. 

3. Compensatory, such as occurs when, on account of the 
decrease in size of an organ, the surrounding tissues have 
undergone a hyperplasia in order to supply the deficiency. 

Morbid Anatomy. — The part involved may be much 
larger than normal, or on account of the contraction of the 
newly formed connective tissue, be much smaller. In either 
case the change is not symmetric. ^ 

In elephantiasis the part involved will beflprge on account 
of the increase in cells, but it will be very irregular. 

In hyperplasia of the connective tissue of the liver the 
organ may be smaller than normal and have a roughly gran- 
ular surface. 



94 A MANUAL OF PATHOLOGY 

Metaplasia refers to the transformation of one tissue into 
one of another variety. The new variety must, however, be 
one derived from the same blastodermic layer. Epithe- 
lium can never be transformed into a connective-tissue 
type nor vice versa. The term is practically limited to the 
connective-tissue group. It is seen in the formation of fat 
from areolar tissue, of bone from fibrous tissue, etc. 

Heteroplasia is the development of a new tissue in a 
locality where it is not normally found. This is seen par- 
ticularly in connection with neoplasms. 



CHAPTER IX 
TUMORS OR NEOPLASMS 

A tumor is a functionlcss new growth, atypical in struc- 
ture and frequently harmful to the individual. 

The cause of such growths is as yet unknown. They are 
made up of tissues that have their counterpart either in the 
embryonal or adult development. They differ in having a 
more or less atypical arrangement, in occurring in tissues 
in which they are heterologous, and in not having any 
mechanism to control their growth and function. 

Theories of Origin. — They are numerous, but as yet 
no one answers in every case. 

1. S per malic Influence. — It was thought that the normal 
tissue where the growth occurred had become directly trans- 
formed into the tissue of the tumor, but this is not in any way 
supported. 

2. Mechanical Irritation Tlieory oj Virclwiv. — By this it is 
claimed that new growths arise in tissues that have been the 
seat of injury or chronic irritation. Such cases as the devel- 
opment of epitheliomata on the lower lips of pipe-smokers, 
carcinoma of the gall-bladder associated with gall-stones, 
scrotal cancer in chimney-sweeps, etc., would seem to uphold 
this theory. It is probable, however, that the injuries and 
irritation are not the causative, but are secondary factors. 

3. Theory oj Embryonic Remnants (Cohnheim). — The 
author of this theory believed that "in an early stage of em- 
bryonic development more cells were produced than were 
required for the formation of the tissue involved, so that 
there remained unused a number of cells, possibly very 
few, which, on account of their embryonic character, were 
endowed with the power of marked proliferation." These 

95 



96 A MANUAL OF PATHOLOGY 

remnants are frequently spoken of as "rests." Cohnheim 
thought that they could lie latent for many years and develop 
in after life if conditions should become favorable. 

Although these "rests" have never been discovered, yet 
in certain forms of tumors this theory seems to hold good: 
in enchondromata of the testis and parotid glands and of 
other organs, and particularly in the case of the dermoid 
cysts. 

4. Parasitic or Injcctivc Theory. — Many investigators 
have claimed, especially concerning the carcinomata and 
sarcomata, that tumors arc caused by the presence of living 
micro-organisms. Bacteria were first supposed to be the 
cause. Later, small round bodies, known as "Russell's 
bodies," were found in cancer cells and were thought to be 
protozoa. 

PHmmer more recently believed the cellular inclusions 
to be blastomycetes. 

Cultivation of these bodies has generally failed and the 
result of transplantations of portions of tumors has not been 
satisfactory. 

Many believe the inclusions to be portions of degener- 
ated nuclei or secretions of the cells. 

5. Theory oj Decreased Tissue Resistance. — Ribbert's 
theory is that the connective tissue loses its normal resist- 
ing power, or "tissue tension," and by doing so allows the 
epithelial cells to undergo abnormal proliferation. 

6. Nervous Theory. — This was to the effect that through 
disturbances of the trophic nerves the tissues were able to 
undergo an overgrowth. 

Predisposing Causes. — Age. — Certain tumors appar- 
ently bear a distinct relationship to the age of the individ- 
ual. Before thirty years the sarcomata are m.ost likely to 
appear; after that period, the carcinomata. 

Sex. — Women are much more predisposed to tumor for- 
mation than are men. 

Heredity seems to have some influence, as it has been 
found that carcinomata are more common in some families 
than in others. 



TUMORS OR NEOPLASMS 97 

Occupation, as in chimney-sweepers and in paraffin- 
workers, who seem to frequently suffer from carcinoma. 

Morphology. — Tumors may differ greatly in the follow- 
ing respects : 

Size. — They may be of any size, from microscopic to 
weighing 275 pounds, as reported by Delameter. 

5/2^^^.— According to their shape tumors are called nodu- 
lar when spherical, tubercles when projecting as a rounded 
body above the surface of an organ, -flat or tabular when 
rising as a comparatively level elevation. 

When the growth is connected to its original site by a 
stalk or pedicle it is called a polyp. When the surface is 
very roughened and irregular the tumor may be termed a 
cauliflower or de^idritic growth. 

If Hke a mushroom with a narrow stalk and a broad head, 
is termed a fungus. 

Color. — The color of a growth depends upon the nature 
of the tissue of which it is composed and upon the amount 
of blood present. It may also be modified if degenerative 
processes have taken place. 

Consistency depends upon the structure of the growth. 
If of bone the tumor will be very hard; if of mucous tissue, 
very soft. 

Number. — Tumors may be single or multiple, there 
being usually a single primary tumor with several secon- 
dary ones ii the growth is malignant. There may, however, 
be hundreds of primary tumors, as in cases of fibroma mol- 
luscum. 

A recurrent tumor is one that recurs at the place from which 
it was removed. 

According to the arrangement, tumors may be typical, 
homoplastic, or homologous when they resemble the tissue 
from which they arise; atypical, heteroplastic, or heterol- 
ogous when they dift'er. 

If made up of a simple tissue they are called histoid tumors; 
if of a combination, attempting the formation of an organ, 
organoid; and when containing portions of all three blas- 
todermic layers, teratoid. 
7 



95 A MANUAL OF PATHOLOGY 

The blood-vessels, which always originate from prc-e'xist- 
ing vessels, may be greatly increased in number, telangiec- 
tatic; in size, cavernous; or unusually arranged, plexijorm. 
They may be greatly decreased in number, thereby favor- 
ing secondary changes, or their walls may be imperfectly 
formed, giving rise to hemorrhages. Lymphatics are usu- 
ally present, but the nervous supply is very poor, as a rule. 

The growth of a tumor is independent of that of the indi- 
vidual. It may continue even if the normal tissues are being 
sacrificed for it. A lipoma will grow although the patient 
may not be getting sufficient nourishment to carry on the 
normal functions of the body. 

It may be either central expansion, as is the case in benign 
growths, or peripheral infiltration, as in the mahgnant forms. 
The latter also increase by means of the. central expansion. 

As the blood-supply of tumors is usually poor, they fre- 
quently undergo various forms of degeneration, as pig- 
mentation, calcification, jatty, hyaline, colloid, and mucoid 
metamorphoses; necrosis and ulceration. 

According to their effect upon the individual a new growth 
may be either benign or malignant. 

Benign growths do not affect the patient except as they 
may press upon vital structures or undergo degenerative 
processes. 

They are usually circumscribed, encapsulated, do not give 
metastases, and do not recur after excision. 

Malignant tumors are those that through their own 
influences tend to bring about the death of the individual. 
They are not circumscribed, nor encapsulated, cause 
cachexia, give metastasis, and recur after excision. 

Metastasis refers to the extension of the primary growth 
by the transference of malignant cells to other parts of the 
body. It may take place either through lymphatics, as in the 
carcinomata, or through the blood, as in the sarcomata. 

Death may be caused by tumors — 

1. Pressing upon vital organs. 

2. Invading vital organs and causing degeneration. 

3. Hemorrhage resulting from ulceration and degeneration. 



TUMORS OR NEOPLASMS 99 

4. Absorption of poisonous products. 

5. Secondary injection. 

6. Exhaustion due to the tumor using up so much nutri- 
tion for its own benefit. 

Combinations of tumors that have been derived from 
the same blastodermJc layer frequently occur, as fibrosar- 
coma, etc. One type cannot, however, be transformed into 
another. 

Classification of Tumors. — The simplest is as follows: 

>-^I. Histoid. 

Simple Connective-tissue Tumors. 

Atypical. ^ Typical. 

Embryonic type Sarcoma. Connective tissue. 

Adult type Fibroma "I o r*. ' Connective tissue. 

/I Lipoma. Fatty tissue. 

*''^'''*^' ■ Myxoma. Mucous tissue. 

> " Chondroma. Cartilage. 

Osteoma. Bone. 

Glioma. Neuroglia. 

Specialized Connective-tissue Tumors. 

, , ^ / Rhabdo- ^.,.jl . /i /.'r: ./..._ Striated muscle. 

^ \ Leio- ■ .^/ )./. . ,yfi r: ^7 . . . .Non-striated muscle. 

Hemangioma Blood-vessels. 

Lymphangioma Lymph-vessels. 

Lymphadenoma Lymphatic tissue. 

Lymphoma Lymphatic tissue. 

Type of Endothelium. 

Endothelioma. 

II. Organoid. — Epithelial Tumors. 

Neuroma Nerve tissue. 

Squamous epithcUjt^fna Squamous epithelium. -..^.^^^^ 

^ , Hard papilloma Squamous epithelium. 

* 0^» Soft papilloma Columnar epithelium. 

;r -f Cylindric epithelioma Columnar epithelium. 

, Adenoma- v '-.'■>. > -.^ 1 1 j 1 4. r n 

TT, „_^ 1 r Normal glandular tvpe of cells. 

Hypernephroma ) & . t 

Carcinoma Atypical glandular cells. 

LOFC. 



lOO A MANUAL OF PATHOLOGY 

III. Teratoid— Mixed Tumors. ^ J^^^ ' * n-'-'^^^ 

Dermoids. 
Teratoma. 
Cholesteatoma. 

IV. Syncytioma Malignum. — ChoriO'Cpithelioma. — Prob- 
ably belongs under the epithelial tumors, ^laa^^^^ ^tj^fe^^ ^ 

TUMORS OF EMBRYONAL CONNECTIVE TISSUE 

SARCOMA 

A sarcoma is a tumor made up of cells that resemble 
those found in embryonal connective tissues. They are 
characterized by the preponderance of the cells over the 
intercellular substance, which may be granular, fibrillary, 
or reticular. The sarcoma cells are not truly embryonal, 
as they never continue to a complete development. They 
arise from the mesoblastic layer and often retain the char- 
acteristics of the tissue from w^hich they arise, periosteal 
sarcomata sometimes containing bone. 

The sarcomata are essentially malignant; that is, they 
infiltrate the surrounding tissues, give metastasis, cause 
cachexia, and return after excision. It is only occasionally 
that they are encapsulated. 

The blood-vessels are generally few in number and im- 
perfectly formed, the single layer of endothelium being 
supported by a very few connective-tissue fibers. In many 
cases the blood-channels are simply spaces whose walls are 
formed by the tumor cells. The imperfect vessel wall ex- 
plains why hemorrhage in these tumors is so common and 
why metastasis takes place by means of the blood. 

Sometimes the blood-spaces may be very large and nu- 
merous, thus forming the angiosarcoma. 

As a rule, no lymphatics are present. 

Sarcomata may occur in any part of the body; as a rule, 
they are seldom primary within organs. 

They generally occur before the age of thirty. Are fre- 
quently rounded in shape, somewhat lobulated, and to a 
certain degree circumscribed. Are hard - or soft accord- 



TUMORS OR NEOPLASMS lOI 

ing to the amount of intercellular substance present, or to 
the variety of the tissue of which they are composed. 

Their color is generally pink or grayish; this, however, 
depends to a great extent upon the condition and number 
of the blood-vessels. 

On account of the poor blood-supply, degenerations, 
particularly myxomatous, frequently take place. 

If there is pigment present, either melanin or hemo- 
siderin, the tumor is called a pigmented one. 

These tumors vary greatly in their malignancy, the small 
round- cell type, especially if melanotic, being rapidly fatal. 
The greater the amount of cellular elements, the greater is 
the mahgnancy. 

The varieties of the tumors depend upon the kind of 
cell that predominates. 

Round-cell sarcomata are those made up of either large or 
small round cells. 

In the S7nall-cel\ variety the intercellular substance is very 
scanty. They are rather soft, whitish in color, friable, and 
a milky juice can be scraped from the cut surface. 

They grow rapidly, infiltrate the surrounding tissues, 
give extensive metastasis, recur quickly after removal, and 
soon cause death. They may occur in any part of the body 
and at any age. 

The individual cells have large vesicular nuclei and com- 
paratively little protoplasm. 

If there is a close resemblance to the arrangement of a 
lymph-node, small round cells with a distinct reticulum, the 
tumor is called a lymphosarcoma. 

The large round-cell sarcoma is very similar to the small, 
but is firmer on account of the intercellular connective 
tissue present. The cells are larger, and although generally 
round, may be polygonal, and are sometimes arranged in 
alveoli. 

Arc less mahgnant than the small. 

Spindle-cell sarcoma is one that is made up of spindle cells, 
either large or small. Is one of the commonest forms. 

These tumors are quite firm, white, and very little juice 




'^^'^ 



Fig. 24.— Small Round-cell Sarcoma of the Lower Jaw. Oc. 3; ob. 
D. D. (McFarland). 







2-, 







Fig. 25.— Spindle-cell Sarcoma from the Brain. Hemat.-eosin. X 

300 (Diirck). 
I, Spindle-cells cut longitudinally; 2, spindle-cells in transverse section. 

102 



TUMORS OR NEOPLASMS 



103 



can be scraped from the cut surface. The cells are arranged 
in irregular bundles and have oval vesicular nuclei. The 
amount of intercellular tissue may be very great, making the 
tumor quite hard; is then known as a fibrosarcoma. It is 
often difficult to determine whether the tumor is a sarcoma 
or a fibroma. 




mm^ 



.^i^'. 







i^f 



ic^-* 






Fig. 26. — Giant-cell Sarcoma of the Thigh (McP'arland) 
a, Giant cells; b, spindle cells. 



The spindle-cell sarcomas are relatively benign; they 
frequently do not give metastasis, although recurring after 
removal. 

Giant-cell sarcoma is one in which there are found cells 
made up of a large amount of cytoplasm in which are nu- 
merous oval nuclei centrally located. The predominating 



104 A MANUAL OF PATHOLOGY 

cells may be round or spindle-shaped. They are most com- 
monly found in relation with bone and periosteum. 

This form is the least malignant of all the sarcomata. 

Special names have been given to other forms of sarcoma 
on account of some special feature. 

Alveolar sarcoma is where either groups of round or spin- 













Fig. 27. — Alveolar Large Round-celled Sarcoma from the Perios- 
teum. Hemat.-eosin. X 250 (Dtirck). 
I, Heavy septum of connective tissue; 2, delicate connective-tissue 
reticulum: 3, polyhedral cells with vesicular nuclei. 



die cells are surrounded by distinct bands of connective 
tissue. 

Melanolic sarcoma is one of any type in which there is 
melanin present. This pigment may be found either in the 
cells or in the intercellular tissue. 

They occur in the skin, the choroid coat of the eye, and 
in the ciliary body. 



TUMORS OR NEOPLASMS 



105 



Are very malignant, give widespread metastasis, and 
rapidly prove fatal. The liver is the common secondary 
seat for primary melanotic sarcoma of the eye. 

Myxosarcoma is one in which there is a marked mucoid 
degeneration present. 

Angiosarcoma is a growth that contains many blood- 
vessels. If the walls of these vessels or the neighboring 




Fig 



18. — Alveolar Small round-cell Sarcoma. Zeiss, Oc. 4; ob. c. 
(McFarland). 



cells undergo a hyaline degeneration, the sarcoma is spoken 
of as a cylindroma. 

If the tissue with the exception of those cells in the imme- 
diate neighborhood of the vessels undergoes a mucoid 
change, the growth is called a myxangiosarcoma tubular e or 
perithelioma. 



Io6 A MANUAL OF PATHOLOGY 

Chloronia is a variety of sarcoma arising from the perios- 
teum; is greenish in color. 

Psammoma is a tumor alhcd to the sarcoma. It is made 
up of masses of spindle cells, which contain areas of hyaline 
degeneration and calcification. x\re usually found in the 
meninges of the brain and spinal cord. 

Endothelioma is a tumor arising from endothelial cells. 
These growths are at times very difficult to differentiate from 
carcinoma on account of the apparent cell nest arrangement. 



i7^v* y. 



* r #\ ' "^ 



Mi^ff^^ .! 









....-I 



a 



Fig. 29. — Metastatic Melanosarcoma of the Peritoneum. Hemat.- 
eosin. X 320 (Diirck). 
I, Nests of darkly pigmented polygonal cells; 2, cross-section of vessels. 

The cells extend along the lymphatic spaces and are closely 
related to connective tissue. Are found in the serous mem- 
branes, testicle, ovary, and liver. Are malignant. 

According to the combination of tissues present, the fol- 
lowing varieties will be only mentioned: 

Osteosarcoma = bone present. 

Chondrosarcoma = cartilage present. 
Myosarcoma = muscle present. 

Neurosarcoma = nerves present. 



TUMORS OR NEOPLASMS 



107 



TUMORS OF ADULT CONNECTIVE TISSUE 

Fibroma is a tumor of fibrous connective tissue. Fibro- 
mata are usually pale in color, round, lobulated, circum- 
scribed, and encapsulated. They may be of varying degrees 
of firmness. 



■-' '". If^Ti''-" ' sxV"9*5^>. "• 



























---^iZia^^K 




Fig. 30. — Perithelioma of the Retina (McFarland)j 
a, Blood-vessels surrounded by cells in a good state of preserv^on/ h, 
degenerated portion of tumor. / 



The cells resemble those of normal connective tissue and 
are arranged in bundles that cross each other in all direc- 
tions. 




Fig. 31. — Endothelioma of the Pleura. (Zeiss, Oc. 2; ol). c.) (Mc- 

Farland). 

The illustration shows the cellular growth in the form of cylindric masses 

which fill crevices of the tissue, probably originally lymphatic channels. 









An^ 



^^>^ 

^!.!^-^ 



Fig. 32. — .Hard Fibroma (Warren). 
108 



TUMORS OR NEOPLASMS lOQ 

In the soft variety the cells are separated by serous or 
mucous deposits. 

In the hard the cells are closely packed together. 

Fibromata are bcnigr^'^aftd frequently undergo various 
degenerations. Occur in all parts of the body, particularly 
in the uterus, where they attain great size. In this locahty 
are usually combined with muscle tissue, forming the fibro- 
myomata. 

They may occur in combination with sarcoma, or any of 
the various forms of adult connective tissue, as fibrolipomaj 
myxoma, chondroma, etc. 

A keloid is a fibrous tumor that forms usually from a scar. 
It is not confined to the seat of the original injury, but ex- 
tends somewhat into the surrounding tissues. Is usually 
smooth, and is most frequently seen in negroes. 

Molluscum fibrosum is a condition in which there are nu- 
merous subcutaneous nodules made up of areolar connective 
tissue. In them nerve- fibers are frequently found. 

Epulis is a fibrous growth originating from the gum, 
usually at the site of diseased teeth. 

Myxoma is a benign tumor made up of mucous tissue. 
Is usually pale in color, round, lobulated, encapsulated, and 
feels semifluid. On section a thick, viscid fluid exudes. 

Microscopically spindle and stellate cells with long pro- 
cesses that anastomose are seen. In the meshes between 
the cells and processes is the mucous material. This sub- 
stance is precipitated by acetic acid. 

They occur in sheaths of tendons and nerves and in nasal 
and pharyngeal polyps, and in combination with sarcoma. 
Mucoid growths forming from degeneration of fibromata are 
not true examples of myxomata. 

Lipoma is a benign tumor made up of fatty tissue. Is 
yellow in color, round, lobulated, encapsulated, and soft. 
May be very large. Microscopically the cells resemble ordin- 
ary fatty tissue, except in being considerably larger and the 
connective tissue trabccuUc are also thicker than normal. 
Occurs most commonly in the subcutaneous tissue, in fasciae, 
and in synovial membranes. Is slow in growth and will 



no 



A MANUAL OF PATHOLOGY 









t ^ 








Fig. 33.— Myxomatous Fibroma of the Nasal Mucous Membrane 

(Diirck) 
Stellate connective-tissue cells joined together with protoplasmic pro- 
cesses; the intercellular substance has become myxomatous and contains 
abundant masses of leukocvtes. 



TUMORS OR NEOPLASMS 



III 



frequently persist even if the individual is much emaciated. 
Occurs in combination vvath sarcoma, myxoma, fibroma, 
and angioma. 

Chondroma is a growth composed of either hyahne or 
fibrous cartilage. 

Arises from periosteum or the medullary substance of the 
long bones. If it is found in localities where periosteum 
does not exist, as in testicles, is called an enchondroma. 




Fig. 34. — Lipoma from the Region of the Shoulder with Relatively 
Small Fat Cells. (M. F1. Ham.) X 300 (Ziegler). 



Is hard, encapsulated, and lobulated. Is slow in growth, 
may persist for years, and become very large. 

Frequently undergoes mucoid degeneration and calcareous 
infiltration. 

Is benign, but in combination with sarcoma may be quite 
mahgnant. Is also found in combination with lipoma, fi- 
broma, and myxoma. An ccchondroma is a small over- 
growth of cartilage. Are found on the edges of the artic- 
ular, laryngeal, and nasal cartilages. 

Osteoma is a tumor composed of bone. It may be a 



112 A MANUAL OF PATHOLOGY 

result of inflammatory processes of the periosteum or be 
a distinct new growth. 

If developing from a bone-forming tissue, is called Sihoinol- 
ogous osteoma. 

If arising in a tissue that is not bone-forming, is called 



H.. 




Fig. 35. — Hyaline Chondroma. Oc. 2; ob. 3 (McFarland). 

a heterologous osteoma. The latter are found in the meninges, 
lung, and parotid gland. 

An osteoma is a hard, bony, rounded, and more or less 
lobulated growth. Microscopically it presents quite typically 
the normal structure of bone. May be composed of spongy 



TUMORS OR NEOPLASMS II3 

or compact new bone, osteoma spongiosum and osteoma 
durum. 

If the growth is small, circumscribed and flat, and arising 
from pre-existing bone, it is called an osteophyte. If irregular 
and projecting, an exostosis. 

Occurs most commonly at the epiphyses of long bones. 
Is benign. May be in combination with cartilage, fibrous 
tissue, fat, or sarcoma, in which latter case it is mahgnant. 




Fig. 36. — Osteoma OF THE Lung. Hemat.; bleu de Lyon. X 75 (Diirck). 

I, Bone-trabeculoc; 2, fibrous interspaces not presenting the characters 

of medullary spaces. 



Myoma is a tumor composed of newly formed muscle- 
fibers. According as to whether the muscle is striped or 
voluntary, or unstriped and involuntary, w^e have the rhah- 
domyoma and the leiomyoma. 

The first is very uncommon. 

The latter occur frequently in the uterus and broad liga- 




114 



A MANUAL OF PATHOLOGY 



ment, but may arise wherever there is involuntary muscle. 
Are firm, round, lobulated growths, dark reddish in color. 

Are benign, slow of growth, and frequently undergo cystic 
or calcareous degeneration. The cysts contain mucus. 




Fig. 37.— Leiomyoma of the Uterus (Uterine Fibroid). Oc 4; 
3 (McFarland). 



ob. 



Usually are in combination with fibroma. 

Neuroma is a tumor composed of nerve tissue. As the 
term has been applied to all growths found on nerves, 
two divisions are made, the true neuroma, which consists of 



TUMORS OR NEOPLASMS 



115 



nerve tissue, and the jalse neuroma, which consists of fibro- 
connective tissue. 

The true is called a ganglionic neuroma when ganglionic 
nerve-cells are present; if nerve-fibers only are present, is 
called a fibrillar neuroma. 

Hemangioma is a tumor made up of blood-vessels. 




Cavernous Angioma (Warren). 



Angioma simplex or ncevus when the vessels are small and 
very much interwoven. 

Cavernous angioma w^hen the blood-spaces are large and 
separated by distinct fibrous bands. Resembles the struc- 
ture of the corpus cavcrnosum of the penis. 

Plexijonn angioma when a group of more or less paral- 
lel blood-vessels become tortuous and widely dilated. 

Lymphangioma is a tumor caused by a dilatation of 



Il6 A MANUAL OF PATHOLOGY 

lymphatic vessels with an arrangement quite similar to that 
of the hemangioma. 

An odontoma is a tumor resulting from the imperfect 
development of a tooth. 

According to Sutton, there are the following varieties: 

Those developing from: 

The enamel organ = epithehal odontoma. 

follicular odontoma. 
The tooth folHcle = compound follicular odontoma. 

petrous odontoma. 

cementoma. 
The papule = radicular odontoma. 

The whole germ = composite odontoma. 

1. Epithelial odonloma develop from the enamel organ. 
Microscopically they somewhat resemble an adenoma on 
account of the branching epithelial growths. 

2. Follicular odontoma consist of a wall formed by an ex- 
tended tooth follicle, the cavity of which is filled with a thick 
fluid and contains a part of an imperfectly developed tooth. 

3. Compound jollicular odontoma result from the sporadic 
ossification of a thickened capsule. They contain a number 
of small fragments of cementum or dentine or sometimes 
imperfectly formed teeth made up of cementum, enamel, 
and dentine. 

4. Fibrous odontoma consist of the connective tissue cap- 
sule covering the tooth becoming so thick that the tooth is 
not able to be erupted. 

5. Cementoma is a form of odontoma in which the thick- 
ened capsule over the tooth has undergone ossification. 

6. Radicular odontoma forms after the crown of the tooth 
has been completed and while the roots are in the process 
of formation. It consists of dentine and cementum in vary- 
ing proportions. 

7. Composite odontoma refers to those hard tooth tumors 
which bear little or no resemblance in shape to teeth, but 
occur in the jaws, and consist of a disordered conglomera- 
tion of enamel, dentine, and cementum. 



TUMORS OR NEOPLASMS 



117 



TUMORS OF EPITHELIAL TISSUES 

A papilloma is a tumor composed of projections of fi- 
brous connective tissue that are covered by one or more 
layers of epithelium, either squamous or columnar in type. 

May be divided into the hard and the sojt papillomata. 

The hard occur on the skin as warts, also around the 




Fig. 39. — Tuft of Papilloma of thk Bladder (Stengel), 



genitalia as a result of constant irritation; in which situa- 
tion are known as venereal warts. Are also found on the 
true vocal cords in the larynx. Are covered by squamous 
epithelium which commonly undergoes keratosis, a horny 
change. In this form the "pearly bodies" or ''epithehal 



Il8 A MANUAL OF PATHOLOGY 

pearls" are frequently found. These are made up of cells 
concentrically arranged, many of which have lost their nuclei 
and have become transformed into keratin. They are found 
only in squamous epithehum. 

Papilloma covered by squamous epithelium are frequently 
found in the urinary bladder. 

The soft papilloma occur in the intestine, and are covered 
by columnar epithelium. This form quite frequently under- 
goes malignant transformation. 








Fig. 40. — Papillary Adenoma from the Rectum. Hcmat.-eosin. X 

98 (Durck). 
I, Vascular stroma; 2, stratified cylindric epithelium. 

The connective-tissue stalks may be simple projections 
or very complicated, branching outgrowths. They contain 
blood-vessels and lymphatics. 

An adenoma is a tumor that in its structure resembles 
an epithelial gland. It is frequently very difficult to tell 
whether it is a true growth or only an enlargement of a 
normal gland. 



TUMORS OR NEOPLASMS II9 

In the new growth the tissues, though arranged typically, 
do not carry on any useful function. The secretion may be 
imperfect or there may be no duct through which it can 
escape. 

Adenomata arise from epithehal glands, are circumscribed, 
encapsulated, and rounded, or nodular. Have been found 
in all glandular tissues. 

Microscopically they consist of a framework of connec- 
tive tissue, the meshes of which are covered by one or two 






'> 






Fig. 41. — Alveolar Adenoma of the Mammary Gland. Oc. 2; Ob. 
9 (McFarland). 

layers of epithelial cells that resemble in shape and size 
those of the normal glands. The important point that dis- 
tinguishes these growths from malignant ones is the relation 
of the cells to the basement membrane. In the benign ad- 
enomata the membrane is preserved and the cells show no 
tendency to invade the surrounding tissue. 

If the connective tissue and epithehum are in normal pro- 
portion the growth is called a simple adenoma; if the con- 
nective tissue predominates, a fibro-adenoma. 



120 



A MANUAL OF PATHOLOGY 



If the tumor has a pedicle, is known as an adenomatous 
polyp. 

Through degenerations, particularly colloid or mucoid, 
an adenoma may become very large through cystic forma- 
tion. Is then called an adenocystoma. 

If vilh extend into the acini in the above form the growth 
is called an adenocystoma papilliferum. 




Fig. 42.— Fibro-adenoma of the Mammary Gland (Canalicular Form) 
Oc. 2; Ob. 3 (McFarland). 



Hypernephromata are tumors that resemble the struc- 
ture of the adrenal gland. They result from the growth of 
mclusions of aberrant adrenal tissue. Are found in the kid- 
ney, liver, broad ligament, and in other abdominal tissues. 

Gliomata are growths composed of neuroglia or nervous 
connective tissue. As they arise from the epiblast they 
cannot be classified with the mesoblastic tumors. 



TUMORS OR NEOPLASMS 121 

Are usually small, reddish in color, and not distinctly 
limited from surrounding tissues. 

Microscopically they are composed of cells with large 
nuclei and with long fine processes. 

Blood-vessels may be numerous and many areas of hemor- 
rhage present. 

Are benign and slow-growing. 



1 



tsy^^. ^^/j,^^^' 







Fig. 43. — Adrenal Tumor from the Kidney (Hyperxephroma) 

(Dijrck). (Hemat.-cosin.) 

I, Large polygonal cells, containing an abundance of fat and arranged 

in tubes; 2, connective-tissue cells in the scanty stroma. 



CARCINOMA 

A carcinoma is a malignant tumor of epithelial origin. 
It is characterized by a marked proliferation of epithelium 
with infiltration into the surrounding tissues. 

The epithelium is arranged atypically in a supporting 
framework made up of adult connective tissue. 



122 A MANUAL OF PATHOLOGY 

The epithelial cells are not characteristic of the growth 
but they differ in some respects from the normal type. The 
diagnosis of carcinoma cannot be made from the cell, as 
there is no distinct cancer cell. The general arrangement 
of epithelium and connective tissue must be taken into con- 
sideration. 

The carcinomatous epithelium frequently consists of cells 



^ .1 (^ ■ il. ; f^^^o^: M-^ - -iJ 



"© ®® • ^a^oc 



Fig. 44. — Metastatic Simple Carcinoma of the Dura Mater. Hemat.- 

eosin. X 150 (Diirck). 

I, Solid epithelial plugs lying within alveoli; 2, stroma. 

many times larger than normal. Their nuclei may be un- 
usually large, vesicular, and show a peculiar affinity for 
nuclear stains, a condition called Jiypcrchromatosis. 

They may divide by an atypical mitosis and give rise to 
peculiar arrangements of the chromatin. These cells mul- 
tiply rapidly, and though at first round they may become 
almost any shape on account of the mutual pressure exerted. 



TUMORS OR NEOPLASMS 1 23 

In some cases giant cells occur. Tumors of this variety 
differ greatly in size, shape, color, and density. 

Carcinomata are composed of two types of tissue, epithe- 
hal and connective, cells and stroma. According to the one 
that predominates, carcinomata are called medullary when 
the cells are more numerous; scirrhus when the tumor is 
rich in connective tissue. 




Fig. 45. — Medullary Carcinoma of the Breast, showinx. Necrosis 
IN the Center of the Columns (Low Power) (Warren). 



The first is soft, the second hard. 

Well-developed blood-vessels and lymphatics are found 
in the stroma, which is most likely derived chiefly from pre- 
existing connective tissue, but a certain amount is probably 
new-formed. Elastic fibers are present in the infiltrating 



124 A MANUAL OF PATHOLOGY 

portion of the growth. The cellular elements originate from 
the epithelium normal to the part involved and frequently 
retain the characteristics of the primary cell. 

The more closely connected it is with the original cell, the 
more does the carcinoma cell resemble it. The further 
away it is, the greater is the variation. There is then a 
tendency to revert to the round undifferentiated embryonal 
type. Between the cells no fibrillary substance is found. 



3 ^ 






- ■--....•• .-■:.■>.•'-■->•• /!&«■•■■■> ^•••' iv.'5i';«:^-" ■''••••. 



■:^<:-,: 



Fig. 46. — SciRRHus Carcinoma of the Mammary Gland. Hemat.- 

eosin. X 50 (Diirck). 

I, Broad masses of fibrous connective tissue; 2, more cellular masses of 

connective tissue; 3, narrow canccr-alvcoli. 

In the carcinoma the cells frequently undergo degenera- 
tion, and usually of a form peculiar to the parent tissue. 
If it arose from squamous Cpithehum keratin is found; col- 
loid or mucoid material if derived from mucous membranes. 
The tumor may break down and undergo a fatty change, 
most common in the mammary gland. 



TUMORS OR NEOPLASMS 1 25 

A carcinoma may become infected and show marked in- 
flammatory changes which may be so great as to somewhat 
disguise the true character of the growth. There will be 
an infiltration of the tissues with leukocytes. 

Microscopically a carcinoma consists of columns of cells 
running in all directions, separated from one another by 
fibrous tissues. These columns give the appearance of alve- 
oli filled with epithelium. The columns are branched into 
numerous subdivisions, giving a complicated root-like struc- 
ture. 

As the tumor grows these cells infiltrate and ramify in all 
directions, occupying usually the lymphatic spaces. 

As there is no intercellular substance the cells easily break 
away from the main mass and are carried to the neighbor- 
ing lymph-nodes. This may take place very early and give 
rise to extensive metastasis. These secondary growths are 
usually similar in character to the primary. 

A squamous epithelioma is a carcinoma that has arisen 
from a surface covered by stratified epithelium such as skin 
and certain mucous membranes. It occurs most commonly 
on the cervix, the skin of the face, penis, vagina, and esoph- 
agus, especially wherever there is a junction of skin and 
mucous surfaces. 

It makes its appearance as an indurated mass in which 
ulceration takes place rapidly and exposes a circular surface 
with raised, hard edges. Sometimes it looks at first like a 
small wart. 

Columns of these cells penetrate the tissues and on account 
of pressure arrange themselves in successive layers, the 
inner ones being almost flat and cornificd, forming the epi- 
thelial pearls. Hyperkeratosis is the term used to indicate 
the cornification. 

The presence of these pearls does not indicate that the 
tumor is necessarily malignant; they mean that the growth 
was derived from squamous epithelium. They are also not 
always found in squamous epitheliomata. The growth may 
have been so rapid as not to have allowed cornification to 
take place. 



126 



A MANUAL OF PATHOLOCA' 



The cells are usually quite large and may show numerous 
"prickles." 

This form of carcinoma differs greatly in its malignancy. 
Some may exist for several years without showing much ten- 
dency to spread, but may suddenly grow and cause exten- 
sive destruction of tissue with subsequent death of the patient. 



d. 




W. 




Fig. 47. — Squamous Epithelioma (McFarland). 
a, Epithelial masses; b, epithelial pearls; c, connective tissue; d, capil- 
lary blood-vessels. 



A rodent ulcer in its microscopic appearance resembles 
a variety of squamous epithelioma, but has pccuhar cHnical 
manifestations. 

For many years, eight to twelve, there may be present a 



TUMORS OR NEOPLASMS 



127 



smooth rounded nodule about the size of a pea. Is a soHd 
growth originating beneath the epidermis, and composed of 
sebaceous gland ducts filled with epithehum. 

For apparently no reason it may ulcerate and the most 
extreme destruction of all neighboring tissues take place. 

It arises generally on the face of people over fifty years of 
age. It does not infect lymph-glands, nor give metastasis. 
As a rule, is solitary, but may be multiple and may extend 
in duration over many years. 



Fig. 




— Glandular Cancer of the Cervix Uteri (Stengel). 



An adenocarcinoma is a cancer in which the glandular 
structure is to a great extent preserved, but the epithelium 
has taken on a proliferative growth. It either breaks through 
the basement membrane or else fills up the acini with nu- 
merous layers of cells. Are commonly found in the stomach, 
intestine, and uterus. Grow rapidly, give metastasis, and 
quickly prove fatal. 

The development of carcinoma differs greatly in different 
people. In some cases a continued mild irritation may pre- 
cede. The growth may be very slow, but if for some reason 



128 



A MANUAL OF PATHOLOGY 




Fig. 49. 



TUMORS OR NEOPLASMS 1 29 

there is an increase in the nutrition, as in the pregnant uterus, 
it may suddenly become rapid. 

If the growth is rapid and metastasis extensive the health 
of the patient suffers and cachexia develops. This may be 
the result of pain, of suppurative conditions or from the 
absorption of toxic substances resulting from the disturbance 
of metabohsm. 

The etiology of carcinoma is still obscure. Heredity is 
apparently clear in many cases as a predisposing cause. 

Age is of importance, the majority of cases appearing after 
the age of thirty-five, a time when the resisting power of 
the tissues is beginning to diminish. 

Carcinoma is more common in women than in men. In 
women it is in the genital organs, in men in the intestinal 
tract. 

Irritation and injury seem to at least be of some impor- 
tance as exciting causes, although in themselves it is doubt- 
ful if they can give rise to a carcinoma. 

Loss of resistance of the connective-tissue stroma has been 
advanced, but does not seem logical. Many observers have 
tried to prove that these growths are infectious processes, 
the results of parasitic activity. T^Iany cellular inclusions 
resembling protozoa have been found, but the general opinion 
at present is that these bodies arc nothing more than degen- 
erated cells, or secretions of cells. Experiments to prove the 
infectious nature of carcinomata have not been generally suc- 
cessful. The transplantation of cancer tissue into a normal 
individual has failed. But w^hen placed in another situa- 
tion in the person from whom the tissue w^as excised growth 



Fig. 49. — Adenocarcinoma of the Body of the Uterus. (Cullcn). 
0, May be likened to a main stem from which arise numerous secondary stems, 
which in turn give off delicate terminals, consisting entirely of epithelial 
cells. The glands may be divided into groups a, b, c, d, and c, by the stems of 
stroma /, g, and h. The stems are covered by several layers of cylindric 
epithelium, while projecting into the gland cavities are long slender ingrowths 
of epithelium, devoid of stroma, as seen in /. Very delicate ingrowths con- 
sisting merely of two layers of e[)ithelium are seen at k and k. At / the epi- 
thelium is several layers in thickness, and at ;;/ many layers with leukocytes. 
The arborescent character of the growth and peculiar gland grouping are 
characteristic of adenocarcinoma. 
9 



130 A MANUAL OF PATHOLOGY 

has followed. This has frequently been considered proof of 
the parasitic nature. It probably means nothing more than 
that the pieces of tissue have found surroundings favoring 
their growth; a condition such as occurs in skin-grafting. 

Bacteria, protozoa, sporozoa, gregarinie, blastomycetes, 
ameba^, and fungi have all been suggested as the cause. 
These claims, however, rest upon the form of the bodies and 




Fig. 50. — SvxcYTiAL Masses Invadixo a Venous Channel in a Case of 
Deciduoma ALalignu.m (J. \\'hitri(]gc Williams). 



their staining properties, not upon cultivation and inocula- 
tion. Until these latter can be carried out the parasite theory 
must remain unproven. 

SYNCYTIOMA 

A syncytioma or deciduoma lualignuni is a tumor that 
develops within the uterus from the chorionic villi. It is 
included by many under the sarcomata on account of its close 



TUMORS OR NEOPLASMS I3I 

resemblance to that class of tumor. It probably belongs to 
the organoid or epithelial group of tumors. Is frequently 
referred to as a chorioepithelioma. 

The chief cells of the tumor originate from the syncytium. 
These cells invade the blood-sinuses and the uterine muscle, 
causing extensive and rapid destruction. Myxomatous de- 
generation and necrosis are common. 

The growth gives early metastases, particularly to lung 
and vagina, is nearly always very rich in blood, and quickly 
proves fatal. 

Microscopically various cells are seen. Very large ones 
containing many large nuclei, rich in chromatin, are formed by 
direct division. 

Others much smaller with single well-formed nuclei and 
containing glycogen. Some that resemble lymphocytes, and 
all kinds of forms resembling the above types more or less 
closely. 

These tumors frequently succeed a hydatid mole or may 
follow a normal or interrupted pregnancy. 

TERATOID TUMORS 

A dermoid cyst is a tumor that belongs to the teratoid 
class. That is, it is one in which the three primary embry- 
onic layers are represented. On account of the skin and its 
appendages, such as sebaceous glands, hair, and teeth, being 
the most conspicuous elements, the cyst is spoken of as a der- 
moid. 

They are the result of disturbances of development and 
of the inclusion of the embryonic layers. Are most common 
in the ovary and in the orbit. They occur frequently in 
those parts of the body where fetal clefts have united, in the 
median fissures of the body, at the branchial clefts, etc. 
They are, however, found, as in the ovary and testicle, where 
the origin must be different. According to Wilms, they here 
are the result of parthenogenesis. 

A teratoma is a tumor similar to the dermoid in that it 
has representatives of the three embryonic layers. The 
term is restricted, though, to those in which certain portions 



132 A MANUAL OF PATHOLOGY 

are more completely developed. There may be a rudimen- 
tary limb or gland. It is to this group that the double mon- 
sters belong. 

Teratomata are usually found either at the anterior or 
posterior ends of the vertebral column, along the hnes of the 
median fissures. 

CYSTS 

A cyst is a circumscribed collection of fluid. IMost of the 
cystic cavities are lined either by epithehum or endothelium. 

The contained material may be semifluid, serous, mucous, 
or purulent if infection has occurred. 

Cysts may be either single or multilocular if divided into 
numerous compartments by fibrous partitions. These 
trabecuLT may break down and convert a multilocular into 
a simple cyst. 

Cysts may be divided into the following: 

1. Retention cysts resulting from an obstruction to the out- 
flow of the secretion of a gland. 

2. Exudation cysts, those formed by an increase of fluid 
in a closed cavity, as in the tunica vaginalis. 

3. Liquejaction cysts result from the breaking down of the 
central portion of solid tumors. 

4. Parasitic cysts may occur on account of an inflamma- 
tory reaction around the parasite, or may be formed directly 
by it, in its development. 

5. Dermoid cysts belong to the teratomata, where they are 
described. 



CHAPTER X 
INFECTION AND IMMUNITY 

By infection is meant the successful invasion of the tis- 
sues by an organism. The mere presence of the bacterium 
within the body is not sufficient to cause infection; it must 
enter the tissues and give rise to symptoms that indicate a 
diseased condition. 

There are normally many organisms contained within the 
body, particularly in the alimentary canal, but they give rise 
to no pathologic conditions until they leave their accustomed 
habitat. 

Infection therefore means the entrance of organisms into 
the body with subsequent injury to the tissues involved. 

By an infective disease is meant one that is the result of 
the entrance into and the multii)lication of the organisms 
within the body. 

The symptoms in such a condition are the result of toxins 
produced and not of mechanical disturbances. As a rule, 
no symptoms appear immediately after the entrance of the 
bacterium into the body, as there is not sufficient toxin pres- 
ent. The time between the inoculation and the appearance 
of the symptoms resulting from the toxins is known as the 
period of incnhation. This differs greatly in different dis- 
eases. 

Infection may be affected by certain peculiarities of the 
infecting organisms and of the infected individual. 

The virulence or the disease-producing capacity of the 
micro-organisms may vary. An organism may occur in 
combination with some other bacterium which may be bene- 
ficial or detrimental. The number of the organisms and 
also the avenue of entrance affect the severity of the infection. 

The infections may be exogenous^ those entirely foreign 

^2>i 



134 A MANUAL OF PATHOLOGY 

to the body, or endogenous, those arising from organisms 
already within or upon the body. These latter gain entrance 
into the tissues through the skin and mucous membranes, 
the respiratory tract, the digestive apparatus, the sexual 
organs, and the external ear. 

To have mfcction taking place virulent organisms must 
enter the body in sufficient numbers, and they must fmd a 
soil suitable for their growth. 

When two organisms invade the body at the same time, 
the condition is known as mixed injection. 

If after one organism has caused tissue changes another 
gains entrance and gives rise to pathologic conditions, it is 
called a secondary injection. 

By immunity is meant the power to resist disease. An 
individual may be exposed to infection, but on account of 
some ability to resist does not acquire the disease. 

By susceptibility is meant the lack of resisting power. 

Immunity is either natural or acquired. 

The natural form is an inherited resisting power that is 
common to certain races of men or animals. 

The acquired is that form which has been obtained after 
birth, and may be either active or passive. 

Immunity is termed active when it results from the action 
of the cells within the body either in destroying the bacteria 
or in injuring them. 

Is called passive when it results from the introduction of 
foreign substances into the blood. 

Active immunity is that which follows an attack of an 
infectious disease, and may last for a varying period^. It 
may be very brief, as in cholera; for a longer time, as in 
typhoid; or sometimes for life, as in smallpox. It may 
result from the inoculation of a weakened virus, as in 
vaccination, or it may follow the introduction into the body 
of bacterial toxins without the micro-organisms. 

Passive immunity is that which is obtained l)y the intro- 
duction of the serum from an immunized animal into the 
blood of a non-immune individual. It is supposed that in 
the serum of the former there is a substance, spoken of as 



INFECTION AND IMMUNITY I35 

antitoxin, that neutralizes the toxin in the blood of the 
infected animal. 

By immunity is implied that not only the bacteria are 
destroyed but that their toxic effects are neutrahzed as well. 

It must also be remembered that immunity is a compara- 
tively relative term. The degree of immunity may be re- 
duced by unhygienic surroundings, by noxious gases, by 
fatigue, exposure to abnormal temperatures, abnormalities 
of diet, effect of drugs, pre-existing disease and by injuries. 

THEORIES OF ACQUIRED IMMUNITY 

I. That the bacteria growing in the body used up some 
material that was necessary for their growth and after dying 
left a soil unsuitable (Pasteur and Klebs). 




Fig. 51. — Leukocyte with Incorporated Bacilli, Illustrating Phago- 
cytosis (MctchnikolT). 



2. That in the growth of the bacteria there were elabo- 
rated substances that inhibited their future development or 
activity (Wernich and Chaveau). 

3. That the cells which have successfully defended the 
body against the action of the bacteria acquire and retain a 
greater power of resistance. 

4. That it is due to the activity of certain cells, called 
phagocytes. This is supposed to depend upon the power 
certain cells have of ameboid motion, l)y means of which they 
are able to surround and take up 1)acteria and destroy them. 

Metchnikoff believes that immunity is the result of the 



17,6 A MANUAL OF PATHOLOGY 

positive and negative chemotaxis existing between the phago- 
cytic cells and micro-organisms. He divides the cells into: 

(i) Microphages: eosinophils and neutrophiles. 

(2) Macrophages: large lymphocytes, endothelial and con- 
nective-tissue cells. 

When the bacteria gain entrance into the body the phago- 
cytes are attracted to that portion and they attempt to ingest 
and destroy the invaders. If the immunity of the animal is 
high, many of the organisms will be found within the cells; if 
the immunity is slight, few cells will contain bacteria. 

5. That the blood itself contains substances that exert a 
destroying influence upon the micro-organisms or its pro- 
ducts. The proteid occurring in animals naturally immune 
is called asozift; if in acquired immunity, a phylaxin. If 
these bodies destroy the bacteria, they are knowTi as mycoso- 
zins and mycophylaxins; if they neutralize the toxins, they 
are known as toxosozins and toxophylaxins. 

The sozins act upon the blood-cells and bacteria, causing 
cytolysis or bacteriolysis, but are themselves destroyed by 
heating at a temperature of 55° to 6o°C. for an hour. These 
bodies are also known as alexins. 

The phylaxins arc the true antitoxic bodies. They are 
more resistant to heat, are capable of acting after being ex- 
posed to a temperature of 80° C. 

6. Ehrlich's Lateral-Chain Theory. This receives its name 
from its analogy to the benzole ring, but is indicated in terms 
that can be applied to hypothetic morphologic bodies. 

In this it is claimed that immunity depends upon the pres- 
ence or absence of ''receptors." The receptor is that body 
attached to the cell by means of which the cell is acted upon 
by various substances, nutritive or otherwise. Each receptor 
is supposed to be so formed as to unite with other bodies of a 
definite character. In the action of the organisms upon the 
cells the toxic sul^stances are considered as being formed of 
two bodies, the "haptophorous" and the "toxophorous" 
CTOups. The combination is supposed to take place as 
follows: The haptophoric group unites with a certain defi- 
nite receptor, and by so doing interferes with the normal 



INFECTION AND IMMUNITY 



137 



function of the cell. The toxophoric group then is able to 
act directly upon the cell. If it is very powerful the cell is 
destroyed, and if a sufficient number are involved the indi- 
vidual may die. 




Fig. 52. 
Cells with various receptors or haptophorous groups of the first order 
(a), adapted to combination with the ha])tophorous groups (b) of various 
chemical compounds brought to them. It will be noted that there is no 
mechanism by which the toxophorous elements of the molecules (c) can be 
brought to the cell. 




Figs. 53 and 54. — Show the Regeneration of the Cell-haptophores 
OR Receptors to Compensate for the Loss of Those Thrown Out 
OF Service. 



If this docs not occur, the cell will be so stimulated that 
new receptors similar to the ones destroyed will be formed. 
There may be such a fresh su]:)ply that many will be cast 
forth into the circulation. These cast-olT receptors form 



138 



A MANUAL OF PATHOLOGY 



the antitoxin, and by coming in contact with the poison unite 
with and neutrahze it. 

In bacteriolysis and hemolysis the destruction is brought 
about indirectly. Besides the cells, two other bodies are 
concerned. One is known as the amboceptor^ intermediate 
or immune body. It is found during the production of the 
cytolytic sera, is not destroyed by heat up to 8o°C., and is 
consequently termed thermo-stabile. 

The second body, known as the complement or alexin^ is 



f ^ 



i^'-m. 



Fig. 55. — Shows the Number of 
Haptophores Regenerated 
BY THE Cell Becoming Ex- 
cessive, They are Thrown 
off into the Tissue Juice. 




1 



Fig. 56. — Explains What Anti- 
toxins are and How They 
are Formed. 

The liberated receptors in the 
tissue juice and in the blood, possess 
identical combining affinities with 
those upon the cell, and meeting the 
adapted ha])tophorous elements in 
the blood, combine with them, thus 
keeping them from the cells. 



normally present in the serum, is destroyed by a temperature 
of 55° C, and is termed thermo-labile. 

In this the complement unites with the amboceptor, which 
in turn joins with the receptor, in this way allowing the de- 
structive effect to take place upon the cell. 

In acquired immunity the cells of the invaded animal form 
large amounts of the amboceptor, which, being free within 
the blood, unites with and neutraliz(^s the toxins. If the 
supply is sufficient, the individual will recover. In passive 



INFECTION AND IMMUNITY 



139 



acquired immunity large numbers of the amboceptors are 
directly introduced into the patient, and in this way effect 
a cure. 

If an animal, as a rabbit, is injected with the serum of 
another animal, as a dog, it will be found that after giving 
several doses, each a few days apart, the serum of animal I 
will precipitate the serum of animal II when placed in a 
test-tube. This occurs even in very high dilution. 

If instead of the serum the erythrocytes are used, it will be 
found that the serum from No. I will dissolve the red cells 
of No. 11. 




Fig. 57. — Combination of Cell 
(a), Amboceptor (/j), and Com- 
plement (c). 

The amboceptor may unite with 
the cell, but cannot affect it alone. 
The complement cannot unite with 
the cell except through the ambo- 
ceptor, having no adaptation to the 
cell directly. 




Fig. 58. 
Cell with receptors of the second 
order {a) by which the cells fix 
useful molecules, of albumins, etc., 
on one hand (b), and zymogen mole- 
cules (c) on the other hand, and 
make use of the one substance 
through the action of the other. 



The substance causing the first reaction is called a prc- 
cipilin; that in the second case a hemolysin. 

By using various cells certain substances acting upon spe- 
cific structures will be obtained; these are known as anli- 
hodies. 

These anti-bodies receive special names according to 
their method of action upon the cells. 

Those that dissolve cells being known as cytolysins; if 



I40 A MANUAL OF PATHOLOGY 

they neutralize ferments, as anli-enzymcs; if they cause 
agglutination, as agglutinins. 

The substances destroying the cells receive various names 
according to the specific cells acted upon, the destruction 
being known as lysis. 

Thus a baclcriolysin causes bacicriolysis; a spcnnaiolysin, 
spcrmatolysis. 

The bacterial poisons are divided into three classes accord- 
ing to their strength, all of which, however, have the one 
point in common that they contain ha])tophore elements. 
They are known as toxins, toxoids, and toxones. 



CHAPTER XI 
VEGETABLE PARASITES 

Under the heading of Fungi belong the mildews, yeasts, 
and bacteria. They are plants of very low organization, 
do not contain chlorophyl, except very rarely, and derive 
their nutrition from organic compounds. 

This class includes the; 
Basidiomyceles. 

Mycomyceles, the common moulds. 
Phycomycetes, the mucor moulds. 
Blastomyceks or Saccharomycctcs, yeast fungi. 
Schizomycctes, the bacteria. 

They may all be parasitic upon and within the body of 
man, animals, and other plants. The bacteria arc espe- 
cially important on account of their relation to disease and 
their bearing upon general hygiene and i)reventive medicine. 

They break up the complex organic compounds into 
simpler ones, and if they derive their nutrition from dead 
substances arc called saprophytes; if from living tissues, 
parasites; both are found in man. 

The moulds occur as threads or hypha;, in a tangled 
mass, the mycelium, from which filaments covered with 
spores arise. 

The Basidiomycetes have spores borne upon basidia. 

The Achorion sehoenlenii is the fungus of javus or tinea 
javosa. It is found to consist of a mycelium of non-seg- 
mented hypha? from which there extend at right angles 
numerous branches. The hyphae show lateral buds and the 
"yellow bodies" of Krai. The mycelia divide into oval 
bodies or spores. The free ends only seem to be capable of 
reproduction, and peculiar bodies, called conidia, develop 
upon them. This parasite is usually found upon the head; 

141 



142 A MANUAL OF PATHOLOGY 

it develops within the hair-folhcle, surrounds the bulb, and 
penetrates different layers of the hair. 

The lesions are yellowish round plates, varying in size 
from a pinhead to a dime, have a saucer-hke appearance, 
and are covered by crusts through which hairs pass. The 
crusts are made up of masses of hyphas and conidia, are 
easily hfted, and leave a depressed ulcer which contains a 
drop of thick yellow fluid. 

If the crusts are not removed they may unite to form 
large masses. The hairs are lusterless and easily plucked 
out. 

The fungus is transmitted from one person to another and 
may be found in parts of the body where no hair is present, 
as in the nails. 

Mycomycetes. — The mycelia contain many cells. The 
following are the more important of this group: 

The oidiiim albicans, which is the cause of thrush. 

Its microscopic appearance varies greatly. Usually from 
the yeast-hke cells there develop long cylindric hyphae, con- 
sisting of united elongated cells from which numerous oval 
sprouts are given off at the junctions. Bulbous sweUings 
are often found on the ends of the mycelia. 

Is most commonly found in the mouth on the tongue, but 
has been observed in the esophagus, intestines, and vulva. 
It appears as milk-white patches surrounded by hyperemic 
zones. 

Is probably saprophytic, as a rule, and is able to obtain 
lodgment in hving tissues only when the vitahty of the 
individual is much lowered. 

The trichophyton tonsurans, the parasite of *' barber's 
itch," consists of myceha divided into hyphas and forming 
many conidia. 

Is commonly saprophytic, but when parasitic it grows 
usually on hairy parts and penetrates the shaft of the hairs, 
causing them to become brittle. If upon the head there 
results rounded, scaly, and red bald areas varying in size, 
from which short hairs project. 

If the skin is free from hairs the disease appears in red 



VEGETABLE PARASITES 1 43 

patches with a vesicular or scaly surface. These areas may 
extend from one portion to another, the patch first involved 
healing as others are affected. 

The organism multiplies betv^een the horny and cellular 
layers of the epidermis. Sometimes it is found about the 
finger-nails, causing them to become cloudy, scaly, and brit- 
tle, with inflamed roots. 

A parasite supposed to be the same as this is found in 
sycosis parasitica and eczema marginatum. Ringworm also 
results when this fungus is inoculated upon the skin. 

The dusty material present is composed of dried epithe- 
lium and fungus spores, the latter often being arranged in 
chains. 

The microsporon jurjiir is the fungus causing pityriasis 
versicolor. It is composed of delicate threads with rather 
small conidia, which may be empty or contain spores. 
Between the threads are found spherical groups of spores. 

Upon the skin it forms peculiar pale brownish or yellowish 
areas, more or less circumscribed, and varying in size from 
pin-points to spots several centimeters wide. 

The microsporon minutissimum causes erythrasma. The 
myceHa consist of bifurcating threads which may contain 
minute spores. 

It occurs on the skin of the axilla, inguinal and natal 
folds as small, rounded, or irregular well-defined patches of 
a reddish or brownish color. 

Several species of the Aspergillus are known to be path- 
ogenic to man, the A. flaviis, A. jumigalus, and A. niger. 

The most severe results follow when this fungus develops 
in the internal organs of the body, particularly in the lung. 
It occurs in man only when the resistance of the lungs is 
already much lowered by tuberculosis or some other pre- 
existing disease. 

The Phycomycetes are destitute of chlorophyl; the my- 
ceha are uniccUular at first, but sometimes become septate. 
Reproduce usually by spores. 

To this class belong the miicor moulds, two of which have 
been found in man as the cause of disease. May give rise 



144 A MANUAL OF PATHOLOGY 

to inflammation of the external ear and have been found in 
the internal organs. 

The Blastomycetes, or saccharomycetes or yeasts, are 
frequently found in man as harmless saprophytes; are con- 
stant in the ahmentary canal, especially in the mouth and 
stomach. If they gain entrance into the bladder and come 
in contact "with a urine containing dextrose, fermentation 
with gas-formation may take place. 

They occur as microscopic, spherical or ovoid, chlorophyl- 
free, unicellular vegetable organisms. They reproduce by 
the formation of buds, which after attaining some size, break 
off and carry on an independent existence. Sometimes in old 
cultures when the nutritive material is scanty the yeast cells 
develop into long cylindric hyphae that do not bud. 

The many peculiar bodies found in cancer, such as Rus- 
sell's fuchsin body, Plummer's bodies, etc., are believed by 
many to be blastomycetes, but there is little evidence to 
support such a view. 

The Schizomycetes or bacteria constitute the most im- 
portant group of parasites. 

The best method of grouping them is that of Migula, part 
of which is as follows: 

I. Family Coccaceae.— Cells globular, becoming shghtly 
elongate before division, wliich takes place in one, two, or 
three directions of space. Formation of endospores rare. 

1. Streptococcus. — Division in one direction of space only, 
producing chains of organisms like strings of beads. No 
flagella. 

2. Micrococcus. — Division in two directions of space, so 
that fours or tetrads are often formed. No flagella. 

3. Sarchia. — Division in all three directions of space, 
leading to the formation of bale-like packages of cocci. No 
flagella. 

4. Planococcus. — Division in two directions of space hke 
micrococci. Flagellated. 

5. Planosarcina. — Division in three directions of space 
like sarcina, but have flagella. 

n. Family Bacteriaceae. — Cells more or less elongate, 



VEGETABLE PARASITES 145 

cylindric, and straight. Never form spiral windings. Divi- 
sion in one direction only, transverse to the long axis. 

1. Bacterium.' — Without flagella. Occasional endospores. 

2. Bacillus. — Flagella arising from all parts of the sur- 
face. Endosporulation usual. 

3. Pseudomonas. — Flagella attached only at the end of the 
cells. Endospores rare. 

III. Family Spirillaceae. — Cells spirally twisted like a 
corkscrew, or short and curved and representing segments 
of the spiral. Division only transverse to the long axis. 

I. Spirosoma. — Rigid. Without flagella. 
. 2. Microspira. — Rigid. Have one, two, or three undu- 
lating flagella at the ends. 

3. Spirillum. — Rigid. Having from live to twenty curved 
or undulating flagella at the end. 

4. SpirochcEta. — Serpentine and flexible. Flagella not 
observed. Probably swim by means of an undulating mem- 
brane. 

IV. Family Mycobacteriaceae, to which belongs the: 

I. Actinomyces. — Cells in their ordinary form appearing 
as long branched filaments ; growth coherent, dry or crumpled. 
Produce gonidia-like bodies. Cultures generally have a 
moldy appearance due to the development of aerial hyphae. 
Have no flagella. 

V. Family Chlamydobacteriaceae, to which belong: 

1. Cladothrix. — Characterized by pscudo-dichotomous 
branchings. Division transverse. Multiply by the sepa- 
ration of entire branches. 

2. Crenothrix. — Cefls united to form unbranched threads, 
which in beginning divide transversely. Later divide in all 
three directions. 

3. Phragmidiothrix. — Cells at first united into unbranched 
threads. Divide in three spaces. 

4. Thiothrix. — Unbranched cells enclosed in a delicate 
sheath. Divide in one direction. Contain sulphur granules. 

VI. Family Beggiatoaceae. — Cells united to form threads 
which are not surrounded by an inclosing sheath. Septa 
scarcely visible. Division transverse. Motile. 



146 A MANUAL OF PATHOLOGY 

I. Beggiatoa. — Cells contain sulphur granules. 
A more common but less accurate method of classification 
divides bacteria into : 

1. Bacillus. — A rod-shaped organism that is not curved 
or twisted upon itself. Having one diameter distinctly 
greater than the other. 

2. Coccus. — Any small spherical organism: 

(a) Diplococciis when occurring in twos. 
{b) Streptococcus, if in chains. 

(c) Staphylococcus, when in bunches like grapes. 

(d) Tetracocci, when division is in two directions and the 
individuals remain attached. 

(e) Sarcina when dividing in three directions, giving rise to 
bale-Hke packages. 

(/) Zooglea when in irregular masses. 

3. {a) Spirillum. — An organism twisted like a corkscrew 
and rigid; usually has polar flagella. 

(b) SpirochcBta, w^hen cell is flexible, long, slender, and 
without flagella. 

(c) Vibrio. — Short, bent like a comma, usually with a sin- 
gle end-flagellum. 

According to the presence or absence of the flagella bac- 
teria are divided into: 

I. Gymnobacteria, forms without flagella. 

II. Trichobacteria, forms with flagella. 

1. Monotricha. — A single flagellum at one end. 

2. Lophotricha. — A bundle of flagella at one end. 

3. Amphitricha. — A flagellum at each end. 

4. Peritricha. — Flagella arising from all parts of the sur- 
face of the organism. 

Bacteria are composed of plasma or microi)rotein sur- 
rounded by a cell membrane; they sometimes possess a 
capsule. 

Most cocci are non-motile; the other varieties may pos- 
sess flagella and in that way be able to propel themselves. 

Multiplication takes place by simple fission or spHtting 
into two. Occurs very rapidly if there is enough nutritive 
media present and the surrounding conditions are favorable. 



VEGETABLE PARASITES 



147 




Fig. 59. — Types of Micro-organisms. 
I, Coccus. 2, Streptococcus. 3, Staphylococcus. 4, Capsulated 
diplococcus. 5, Biscuit-shaped coccus. 6, Tetrads. 7, Sarcina form. 
8, Types of bacilli (i to 8 are diagrammatic). 9, Non-septate spirillum; 
Xiooo. 10, Ordinary spirillum— (a) comma-shaped element; {b) forma- 
tion of spiral by comma-shaped elements; X 1000. 11, Types of spore 
formation. 12, Flagellated bacteria. 13, Changes in bacteria produced by 
plasmolvsis (after Fischer). 14, Bacilli with terminal protoplasm (Butschli). 
15, (a) Bacillus composed of five protoplasmic meshes; (h) protoplasmic net- 
work in micrococcus (Butschli). 16, Bacteria containing metachromatic 
granules (Ernst Neisser). 17, Beggiatoa alba. Both filaments contain 
sulphur granules— one is septate. 18, Thiothrix tenuis (Winogradski). 
19, Leptothrix innominata (Miller). 20, Cladothrix dichotoma (Zopf). 
21, Streptothrix actinomvces (Bostrom), (a) colony under low power; (&) 
filament showing true branching; (c) filament containing coccus-like bodies; 
(d) filament with club at end. 



148 A MANUAL OF PATHOLOGY 

Sporulation occurs when the conditions favoring multi- 
plication no longer exist. There are then formed small, 
round, highly refracting bodies called spores, which are 
capable of resisting very unfavorable surroundings. They 
differ from bacteria in being able to withstand evaporation 
and quite high degrees of heat. Are called endospores when 
formed within the bacterium, may be in the middle or in one 
or both ends. When the spore is located in the center and 
distends the organism it is called a Clostridium. If the entire 
organism is transformed into a spore it is known as an arihro- 
spore. 

Conditions concerned in the growth of bacteria are: 

Food. — Proteids are best, but carbohydrates will do. 
Many pathogenic bacteria require special media upon which 
to grow. 

Moisture is an almost absolute necessity. Unless it is 
present nearly all organisms will dry up and cease to mul- 
tiply, but spores may first be formed and persist in- 
definitely. 

Oxygen may or may not be necessary. 

Micro-organisms which require the presence of uncom- 
bined oxygen are called aerobic. 

Those not requiring but able to grow in it, jacultative 
aerobic. 

Those unable to grow in it, obligatory anaerobic. 

Those able to grow without it, jacultative anaerobic. 

If able to grow equally well with or without oxygen, 
optional anaerobic. 

Temperature is of the greatest importance. Every micro- 
organism grows best at some definite degree of heat and 
shows variations in its activity as the temperature changes. 
The organisms may, however, be able to endure extreme 
degrees of cold without being destroyed, — can be placed in 
liquid air and yet undergo multiplication when the tem- 
perature is raised. They cannot, however, stand the higher 
temperatures as well, although a few organisms may thrive 
at high degrees (65°-7o° C). They are the thermophilic 
bacteria and live in hot springs. 



VEGETABLE PARASITES 1 49 

Bacteria growing between o° 0.-30° C. are psychrophile. 

10° C.-45° C. are mesophile. 
40° C.-7o° C. are thermophile. 

The pathogenic organisms grow best at a temperature nor- 
mal to the body, 37° C. 

A temperature of from 50° to 60° C. will weaken and 
finally destroy nearly all forms. If they are exposed to 
steam or boihng water at a temperature of 100° C, all bac- 
teria will be killed in a few moments, but the spores are able 
to withstand this heat for some time. If there is no mois- 
ture present, 140° C. may be required before destruction 
takes place. 

Reaction of the medium influences the growth, most or- 
ganisms growing best in neutral or feebly alkahne media, 
although some grow well in strong acids and others in 
marked alkaHnity. 

Many chemical bodies will restrain the growth or destroy 
the bacteria. These bodies may be produced by the bac- 
teria or they may be artificially introduced. ' Those which 
will restrain the growth but will not kill are called anti- 
septics. Those that kill, germicides. 

Light, particularly the direct rays of the sun, will retard 
bacterial growth and in many cases kill the organism through 
the formation of H2O2. Blue rays are particularly effective. 

Absence of motion seems more favorable to growth than 
rapid movement. 

Electricity and X-rays do not seem to have any constant 
effect upon micro-organisms. 

The association of one organism with another may cause 
an increase in its activity, as the growth of the tetanus ba- 
cillus in the presence of other bacteria that use up the 
supply of oxygen. 

The reverse may be true: one organism may destroy an- 
other. The diphtheria bacillus may be killed in time by 
the action of bacillus pyocyaneus. 

Products of Bacterial Growth. — Bacteria may be divided 
according to their products into: 



150 A MANUAL OF PATHOLOGY 

Zymogens, bacteria of fermentation. 

Saprogens, bacteria of putrefaction. 

Chromogens, color-producers. 

Photogens, phosphorescent bacteria. 

Aerogens, gas-producers. 

Pathogens, disease-producing bacteria. 

Bacteria through their activity spHt up complex organic 
substances into simple ones. 

In ferment at ion there is a spHtting up of the carbohy- 
drates. This is the process that takes place in the formation 
of alcohol as a result of the action of yeast. 

Putrejaction is the breaking up of nitrogenous compounds. 
The albumins are first transformed into peptones which split 
up into gases, acids, bases, and salts. Both fermentation 
and putrefaction may result from the enzymes produced by 
bacteria. 

The albumins may become changed into toxalbumins or 
into alkaloidal substances called ptomains. 

"A ptomain is a chemical compound containing nitrogen, 
basic in character, formed by the action of bacteria upon 
organic matter." Ptomains are generally elaborated out- 
side of the living body and cause harm only when introduced 
within it. 

Toxins and toxalbumins are the poisonous substances 
elaborated by bacteria during growth, and it is upon them 
that the disease-producing power of the organism rests. 

The toxins differ from the toxalbumins in that although 
proteid in character they do not give any of the albumin 
reaction. 

The haeterio-proteins also belong to this same group. 
These bacterial products are destroyed by sunlight, by heat- 
ing at 60° to 80° C, by long keeping, and by the gastric 
juices. Tuberculin is an exception; it can withstand 100° C. 
The poisonous bodies may be either soluble or insoluble and 
are generally peculiar to the variety of organism by which 
they are formed. Certain ones seem to select definite cells 
upon which to act, and are called specific. Others, having 
no special selective powers, are non-specific. 



VEGETABLE PARASITES I^I 

Toxins to cause disease must gain entrance to the blood. 
They are very powerful, -^jt ^^ ^ grain of tetanus toxin being 
fatal to an adult. The combating of disease rests upon 
the power of the organism to resist the action of the poisons. 
If the power is enough to neutralize their effects, no symp- 
toms will result. If the resistance is insufficient, disease will 
follow. Other products are: 

Acids, acetic, butyric, lactic, etc. 

Gases, HCO^, H^S, NH,, etc. 

Odors from aromatic substances, as indol, skatol, kresol. 

Pigments, blue, red, orange, black. 

Phosphorescence. 

Reduction oj nitrates. 

Enzymes, which may cause fermentations, putrefaction, 
coagulation of milk, liquefaction of gelatin, etc. 



CHAPTER XII 
SPECIFIC MICRO-ORGANISMS 

Staphylococcus pyogenes aureus is a non-motile, facul- 
tative, anaerobic coccus about 0.8 fi in diameter, occurring 
in groups or singly. 

Stains with aqueous solutions of anilin dyes and by Gram's 
method. 

It gives rise to pus-formation and to pyemia. 

Culture. — On gelatin plates occurs as small whitish col- 
onies, which cause liquefaction on the surface. The orange 
pigment is best seen in the center of the colony. In gelatin 
puncture it grows as a fine white line, developing its pig- 
ment in about three days. Liquefies the gelatin and gives 
an orange-colored precipitate. On agar there is consider- 
able variation in the color; is rarely golden, commonly yel- 
low,- often cream color. Grows as a moist, shining, circum- 
scribed colony; does not liquefy agar. On potato growth 
is luxuriant. Best temperature, 37° C. 

Staphylococcus pyogenes albus is similar in every re- 
spect except that it does not produce any pigment. 

Staphylococcus epidermidis albus is a micrococcus 
constantly present in the skin. Thought to be the S. pyo- 
genes albus in an attenuated condition. Similar to the above. 

Staphylococcus pyogenes citreus, similar, except that it 
produces a lemon-yellow pigment. 

Streptococcus pyogenes is a non-motile, non-liquefying, 
facultative anaerobic coccus that is about 0.4 to i (f. in diam- 
eter, that occurs in chains of 10 to 50 members. 

Stains with ordinary dyes and by Gram's. 

Is found in pus and in erysipelas. 

Culture. — Best at 37° C. On gelatin plates small, colorless, 
transparent colonies develop in from twenty-four to forty- 



SPECIFIC MICRO-ORGANISMS 



153 



eight hours. Are round, granular, with raised edges. Do 
not liquefy. On agar-agar have very delicate, transparent 
colonies that do not coalesce. 

When it gains entrance into the body it gives rise to more 
diffuse and more severe suppurations than does the staphy- 
lococcus. 

Bacillus pyocyaneus is an actively motile, flagellated, 
facultative, anaerobic, liquefying bacillus. Is rather short 
and slender, 0.3 /i X i to 21 iJt. 







^^t 



Fig. 60. — Staphylococcus Pyogem.s Aureus, from an Agar-aoar Cul- 
ture. X 1000 (Gunther). 



Stains, — Ordinary methods, but decolorized by Gram's. 

Is found in pus. 

Culture. — On gelatin plates forms small, irregular, slightly 
greenish colonies. Produces a fluorescence of the neigh- 
boring gelatin. On agar-agar there is first produced a 
soluble bright green pigment along the line of inoculations. 
As the culture becomes older a second pigment forms, caus- 
ingthc medium to become a deep blue-green or dark blue. 

Micrococcus gonorrhoeae is a non-motile, non-liquefy- 
ing coccus found in pairs with slightly concaved surfaces 
opposed. From 0.8 to 1.5 [i in diameter. 



154 



A MANUAL OF PATHOLOGY 



Is a purely parasitic organism; is pathogenic for man 
only. Is found in the pus of gonorrhea, in the cells and also 
free in the serum. 

Stains by ordinary methods but not by Gram's. 

Culture. — Is difficult. Does not grow on any of the ordi- 
nary media. Human blood-serum is the best. On it the 
organism in about twenty-four hours forms isolated, thin, 
gray colonies that later on become confluent. Can be 




Fig. 



6i. — Streptococcus Pyogenes, from the Pus taken from an 
Abscess. X looo (Frankel and Pfeiffer). 



grown on gelatin that contains acid urine and also in plain 
acid urine. 

It gives rise to suppurative inflammations of the mucous 
and serous membranes. May cause malignant endocarditis, 
arthritis, and salpingitis. 

Diplococcus intracellularis meningitidis is a non- 
motile, non-liquefying, optionally anaerobic coccus, found 
usually in pairs, but may occur in short chains. 

Is found within the protoplasm of the leukocytes. 



SPECIFIC MICRO-ORGANISMS 



155 



Stains. — Ordinary ones and Gram's. 

Culture. — Grows best at 37° C., but is not easily cultivated. 
Will develop on agar-agar, glycerin-agar, and in Loeffler's 
blood-serum. Growth is not characteristic; occurs as mi- 
nute round grayish colonies that may coalesce. Requires 
frequent transplanting, 

Diplococcus pneumoniae is a minute, sHghtly lancet- 
shaped, non-motile, non-liquefying, optionally anaerobic 
diplococcus. Usually occurs in pairs, surrounded by a 
capsule that is not pres- 
ent when the organism is 
grown on culture me- 
dium. 

Is found in the sputum 
of lobar pneumonia, in 
the exudate of meningi- 
tis, and sometimes in the 
saliva of healthy people. 
Is the common cause of 
croupous pneumonia, but 
is also found in inflam- 
mations of the serous 
membranes. 

Stains. — Ordinary 
methods and Gram's. 

Culture. — Grows best 
at 37° C.,but has a range 
from 24° to 42° C. Will 
grow upon all culture media except potato. Gelatin plates 
(15 per cent, gelatin) give colonies that are small, round, cir- 
cumscribed white points. On agar-agar the growth is almost 
invisible. 

Bacillus tetani is a motile, flagellated, sporogcnous, 
liquefying, obhgatory anaerobic bacillus. Is found in earth, 
particularly that which has been manured, and in the dis- 
charges from wounds after infection. It is about 0.3 /i X 
2 to 4 (i in size, usually straight, but frequently club-shaped, 
due to the presence of a large round spore. 




Fig. 



62. — GoNococci IN Leukocytes; 
Cover-glass Preparation of Gon- 
orrheal Pus (Warren). 



is6 



A MANUAL OF PATHOLOGY 



Stains. — Usual ones and Gram's. 

Culture. — Will grow only when there is no free oxygen 
present. Grows best in alkaline gelatin that contains 2 per 
cent, dextrose. In stab cultures in gelatin and in agar-agar 
colonies form at right angles to the puncture. In gelatin 
liquefaction begins in the second week. 

This organism is the cause of tetanus in man. 




Fig. 63. — Capsulated Pneumococci in Blood from the Heart of a 
Rabbit; Carbol-fuchsin, Partly Decolorized. X 1000 (Mc- 
Farland). 



B. pneumoniae is an encapsulated, non-motile, non- 
sporogenous, aerobic bacillus, so short that it may resem- 
ble a coccus. Varies, however, in length and sometimes 
occurs in chains of four or more individuals. Is found in 
the sputum and in the lung of croupous pneumonia. 

Stains. — Ordinary methods, but not by Gram's. 



SPECIFIC MICRO-ORGANISMS 157 

Culture. — Ordinary media. In gelatin punctures gas- 
bubbles quite frequently appear, but there is no liquefac- 
tion of the medium. Gives the so-called "nail growth." 
Will grow from i6° to 40° C. 

B. diphtheriae is a non- motile, non-liquefying, aerobic 
organism from 0.4 to i.o /jl broad, by 1.5 to 3.5 //. long, shghtly 
curved and with clubbed ends. Is found in the pseudo- 
membranes of those suffering from diphtheria. It is pecu- 
har in that in a pure culture there will be found individuals 
differing greatly in size and shape. These probably repre- 
sent involution forms, as they are found in greatest numbers 
in old cultures. 



6 






\ 






V 

• • 



-" V 



V 






Fig. 64. — Bacillus of Tetanus with Spores (Frankel and Pfeiffer). 

Stain. — Ordinary methods, but particularly Loeffler's 
methylene-blue. Stains by Gram's. The ends take the 
stain more deeply than the middle. 

Culture. — Ordinary media. Is obtained very easily in 
pure culture. The best medium is Loeffler's blood-serum 
mixture. On it there appears a smooth, smeary, yellowish- 



158 A MANUAL OF PATHOLOGY 

white layer at the end of about twelve hours when grown at 
a temperature of 37° C. To make the diagnosis a swab of 
absorbent cotton is brought in contact with the suspected 
surface and the tube is then inoculated directly. A diag- 
nosis can be made at the end of five hours. On gelatin 
the colonies appear as white points. On bouillon a distinct 
whitish pelhcle forms on the surface. Also on agar, milk, 
and potato. 



I 



/f.^ 






!> 












Fig. 65. — Bacillus DiPHTHEKLf;, from a Culture upon Blood-serum, 
X 1000 (Frankel and Pfeififer). 



Pathogenesis. — When introduced into the individual it 
causes on mucous membranes the formation of a pseudo- 
membrane, composed chiefly of fibrin but containing desqua- 
mated epithelium and B. diphthcriae. Is generally asso- 
ciated with both staphylococci and streptococci, giving rise 
to a mixed infection. Besides the local lesion there is a 
marked and serious intoxication, resulting from the absorp- 
tion of poisonous metaboHc products. 

Preparation oj the Diphtheria Antitoxin. — Virulent diph- 



SPECIFIC MICRO-ORGANISMS 1 59 

theria bacilli are grown in alkaline bouillon containing 2 per 
cent, peptone for a period of three or four weeks at a tempera- 
ture of 37° C. The culture is then heated for tw^o hours at 
65° C. and passed through a Chamberland filter. In this fluid 
there is the toxin. It is kept in sterile bottles in the dark. 

For the purpose of immunization the horse is the best 
animal, as it furnishes a greater amount of antitoxic serum 
in less time than when a smaller animal is used. The horse 
is injected hypodermically with o.i c.c. of the toxic serum. 
In the course of six days a larger dose is given; this is repeated 
about every six days till from 500 to 1000 c.c. can be given 
without ill efl'ects. When the degree of immunity is high 
the blood is withdrawn from a vein and collected in sterile 
bottles. These are placed on ice for about four days and 
the clear serum is drawn off from the coagulated blood. 
This serum is the antitoxin. It is preserved by the addition 
of I : 1000 formaldehyde, phenol, trikresol, carbolic acid, etc. 

The strength of the serum is designated by the term "im- 
munizing units." According to Ehrhch and Bchring, the 
"normal serum" is so strong that o.i c.c. of it would pro- 
tect against ten times the least surely fatal dose of toxin 
when simultaneously injected into a guinea-pig. At pres- 
ent the "immunizing unit" is considered as containing ten 
times the least amount of antitoxin that wnll ])rotcct a 300- 
gram guinea-pig against the action of ten times the mini- 
mum fatal dose of the toxin. 

To determine the strengjih of anv lirivcn serum the minimum 
fatal dose of a sterile toxin for a 300-gram guinea-pig must 
be ascertained. Then determine the least quantity of the 
antitoxic scrum that will protect a guinea-pig against ten 
times the minimum fatal dose of the toxin. The necessary 
dose of antitoxic serum is expressed as a fraction of a cubic 
centimeter and multiplied by ten, the result equaling one unit. 

The value of the antitoxin depends upon its use in the 
early stages, before the third day. It should be employed 
in doses of from 1000 units for a child to 2000 for an adult. 
Smaller doses may be used as a prophylactic in those who 
have been exposed to diphtheria. 



l6o A MANUAL OF PATHOLOGY 

In severe cases more than one injection may be necessary. 
Amelioration of the local and general symptoms indicates 
the favorable action of the serum. 

B. anthracis is a non-motile, sporogenous, liquefying, 
aerobic bacillus, from i /i to 1.5 /^ in breadth by 5 to 20 /^ in 
length. Has square ends and is found either singly or in 
long threads. The organism is found in the blood of the 
infected animal as well as in the local lesions. 

Stains by usual methods and by Gram's. 




Fig. 66. — Bacillus Anthracis (Migula). 

Culture. — Grows readily on all media. On gelatin sur- 
face colonies appear as small, round, grayish-white dots, 
accompanied by liquefaction. In gelatin stabs there is a 
characteristic tree-like growth. 

Growls at temperatures from 12° to 45° C. Toward the 
higher point there is marked formation of spores which 
appear as oval, transparent bodies situated at the middle of 
the bacillus and not causing any alteration in its shape. 

Pathogenesis. — Is the cause of anthrax, wool-sorter's 



SPECIFIC MICRO-ORGANISMS 



l6l 



disease, or malignant pustule. It gains entrance by means 
of wounds, through the respiratory or through the alimen- 
tary tract. The viscera show marked congestion. Under 
the microscope numerous bacilli are seen in the capillaries. 
Symptomatic anthrax is a motile, flagellated, sporogen- 
ous, anaerobic, hquefying bacillus about 0.5 ijl in breadth and 
3 to 5 // in length, with rounded ends, found in the lesions of 
symptomatic anthrax. 




Fig. 67. — Anthrax Bacilli in Glomeruli of Kidney (McFarland). 



Stains. — Usual ones. Not by Gram's. 

Culture. — Is strictly anaerobic. Liquefies gelatin, and 
in stabs forms gas. Colonies are spherical or slightly irreg- 
ular in outline. Forms large oval spores that distort the 
organism. 

Bacillus oedematis maligni is a motile, flagellated, ana- 
erobic liquefying, sporogenous bacillus, 0.8 to i .0 /^ in breadth 



1 62 A MANUAL OF PATHOLOGY 

and 2 to lo fJi in length, with rounded ends. Is found in garden 
earth, in the intestines of heahhy animals, and in the lesions 
of the disease. Is not found in the blood on account of 
the oxygen present. May occur in long chains. 

Stains. — Usual methods, but not Gram's. 

Culture. — Ordinary media. On gelatin forms small, 
shining, grayish-white colonies. Under microscope can see 
long tangled filaments. In glucose-gelatin stabs forms white 
cloudy areas with some slight gas production. 







A-^ 



Fig. 68. — Bacillus Influenza., from a Gelatin Culture. X 
(Itzerott and Niemann). 



It is the cause of mahgnant edema. Is pathogenic for 
most animals, but cattle seem immune. 

Bacillus influenzae is a minute, non-motile, non-hquefy- 
ing, aerobic bacillus found in the discharge from the nose and 
bronchi of those affected by influenza. Is also sometimes 
found in the blood. Is very small, about 0.2 X 0.5 //, are 
usually single, but may occur in chains of three or four. 

Stains. — Ordinary methods, but not by Gram's. 

Culture. — Grows poorly on artificial media. Will not 



SPECIFIC MICRO-ORGANISMS 



163 




Fig. 69. — Bacillus Typhosus, from a Twenty-four-hour-old Agar- 
agar Culture. X 650 (Heini), 




Fig. 70. — Bacillus Typhosus, showing Flagella (McFarland). 



164 



A MANUAL OF PATHOLOGY 



grow at all on ordinary gelatin or agar-agar. Develops best 
upon media containing blood. Colonies appear as minute 
colorless bodies, looking like dewdrops. They do not co- 
alesce. Is easily destroyed; 60° C. for five minutes will kill 
it. Will not grow below 28° C. 

Bacillus typhosus is a motile, flagellated, non-sporo- 
genous, non-liquefying aerobic, facultative anaerobic ba- 
cillus, 0.5 to 0.8 n broad by i to 3 ft long, with rounded ends. 
Seldom seen in chains. Is found in the urine and feces of 
infected individuals; also in the blood, gall-bladder, and in- 
ternal organs. Is present in water and milk as a result of 
contamination. 

Stains. — Ordinary methods, but not by Gram's. 

Cidlure. — Ordinary media. On potato there is formed a 
characteristic, thick, moist and shiny, invisible film. 

Must be distinguished from the B. coli communis. 

The following are the chief differences between the two: 



Colonies on gela- 
tin plates: 



On potato; 



Milk: 



B. TYPHOSUS. 

On- surface large, thin, and 
bluish, with notched 
border; yellow-brown in 
center. Deep colonies, 
b r o w n i s h-y e 1 1 o w and 
sharply circumscribed. 
Non-liquefying. 

Usually forms a thitk, 
moist and shiny, invis- 
ible layer. Sometimes 
yellowish or brownish. 

Slightly acidulated but not 
coagulated. Diffuse 
cloudiness. 



Bouillon : 


No indol. 


Ferments: 


No gas formed in media 


Potassium ni- 


containing sugar. 
Not reduced. 


trate : 
Neutral red: 
Widal test: 


Color remains. 
Positive with the serum of 
typhoid blood. 



B. COLI COMMUNIS. 

On surface large, yel- 
low-brown, round or 
oval with irregular 
border. Below sur- 
face round, yellow- 
brown, homogeneous. 
Non -liquefying. 

Luxuriant growtli. Yel- 
lowish-brown and 
glistening. 

Rapid coagulation and 
acidulation. Turns 
blue litmus red, color- 
ing medium. Marked 
turbidity. 

Indol in twenty-four to 
forty-eight hours. 

Fermentation whenever 
sugar is present. 

Reduced to nitrites and 
then to ammonia. 

Changes to yellow. 

Negative. 



SPECIFIC MICRO-ORGANISMS 



165 



B. coli communis. — See typhoid. Structurally it resem- 
bles the B. typhosus. 

B. pestis. — A minute non-flagellated, non-motile, non- 
sporogenous, non-liquefying aerobic, and facultative anaero- 
bic bacillus. Is very short, 1.7 fi by 2 ij., with rounded ends. 
Varies greatly in shape. Is found in the blood and in the 
enlarged lymphatic nodes. 

Stains. — Ordinary methods, but not by Gram's. The 
rounded ends stain more deeply than the middle, giving an 
appearance of a diplococcus. 

Culture. — Grows well on artificial media. Diffuse cloud- 
iness in bouillon. Gelatin puncture growth scanty. On 
agar-agar forms white or 
bluish-white colonics with 
round uneven edges. On 
agar-agar plus 2.5 percent, 
salt forms marked involu- 
tion forms. Best medium 
for culture is a 2 per cent, 
alkaline peptone solution 
containing i or 2 per cent, 
of gelatin. 

Is the cause of bubonic 
plague in man. Is spread 
by means of rats and flics. 

Bacillus aerogenes 
capsulatus. — A large non- 
motile, non-flagellate, spor- 
ogenous, purely anaerobic bacillus, 0.5 fi broad by 3 to 5 fi 
long, and with rounded or square ends. Occurs in groups 
and in pairs, but not in chains, in this way differing from 
the anthrax baciUus. Is found in the tissues in the necrotic 
areas. 

Stains. — Ordinary methods and by Gram's. The organ- 
isms obtained from the body show distinct capsules. 

Culture. — Ordinary media, but in glucose gelatin shows 
best the characteristic gas-production. Is no distinct lique- 
faction, but the gelatin becomes softer. In deep stabs 




Fig. 



r. — Bacillus of Bubonic 
Plague (Yersin). 



1 66 A MANUAL OF PATHOLOGY 

forms small, knot-like, grayish-white colonies from which 
extend fine hair-like or feathery projections. Produces 
acid. 

Causes emphysematous gangrene with necrosis of the 
tissue before death and the formation of gas post mortem. 

Spirillum cholerae asiaticae is a motile, flagellated, non- 
sporogcnous, liquefying aerobic, and facultative anaerobic 
spirillum; found in short arcs, spirals, and "comma" forms. 
About 0.8 /^ long. Has a single end flagellum. Is found in 




Fig. 72. — Cholera Spirilla, showing Flagella (Muir and Ritchie). 

the feces, never in the blood or tissues, of those suffering from 
Asiatic cholera. 

Stains. — Usual methods, but not by Gram's. 

Culture. — Easily cultivated. On gelatin plates colonies 
appear in lower layer as small white dots. Extend to sur- 
face, causing liquefaction. Are granular. Gelatin stab 
cultures show Hquefaction gradually extending from the sur- 
face downward. Gives rise to an inverted cone with an air- 
bubble at the upper end. In hquid media the presence of 



SPECIFIC MICRO-ORGANISMS 



167 



indol and of nitrites is shown by the addition of one or two 
drops of chemically pure sulphuric acid, a reddish color 
being produced. Forms acid but does not coagulate milk. 




Fig. 73.^ — Spirilla of Relapsing Fever in Human Blood. X 1000 

(Boston). 



The spirilla resembling that of cholera are the following: 
Finkler-Prior spirillum. — Similar in shape but shorter 
and stouter. Actively motile. Growth rapid. Does not 




Fig. 74. — Spiroch.eta Pallida. 



produce indol. Causes extensive liquefaction of gelatin. 
Is found in the feces of cholera morbus. 

Vibrio tyrogenum. — Found in old cheese. Similar in form. 
Growth and liquefaction faster than S. cholera but less rapid 



lOO A MANUAL OF PATHOLOGY 

than Finkler. Is actively motile and has an end flagellum. 
Forms yellow, irregular, distinctly circumscribed colonies. 

Vibrio Metschnikovi is a spirillum closely resembling that 
of cholera and is found in the feces of chicken cholera. Is 
somewhat thicker and shorter than the S. cholerae. Growth 
is very similar to that of the cholera spirillum but is slower. 
Not pathogenic for man, but kills chickens, pigeons, and 
guinea-pigs. 

Spirillum of relapsing fever is a long, undulating, 
actively motile, flagellated spirillum, about o.i n in diameter 
and 20 to 40 n long. Non-sporogenous. Are found in the 
blood of patients during the height of the attack, but disap- 
pear after the temperature has fallen. 

Stains by ordinary methods, but not by Gram's. 

Ciihiire. — Has never been grown outside of the body. 
Can be transmitted to monkeys by inoculating with infected 
blood. 

Spirochaeta pallida is an organism recently thought to be 
the cause of syphilis. It is very delicate, weakly refractile, 
and very motile. Is long, thin, spiral or corkscrew shaped, 
with pointed ends. Is from 4 to 10 // long, 0.25 /i thick, and 
contains 6 to 14 turns, which are narrow and regular. This 
organism is difficult to stain; best results are derived from 
Giemsa's or Romanowsky's stains. Are difficult to find, 
both on account of their minuteness and their scarcity, few 
being found, as a rule, in a single preparation. They are 
found in the various primary and secondary lesions and in 
the blood, but not during the tertiary stages. Have not 
been artificially cultivated. 



CHAPTER XIII 

THE SPECIFIC GRANULOMATA 

TUBERCULOSIS 

Tuberculosis is a specific infectious disease characterized 
by the formation of tubercles. 

Is caused by the B. tuberculosis, which is non-motile, 
non-sporogenous, aerobic, acid-resisting, and purely para- 
sitic. Occurs as a slender, rod-shaped, slightly curved 
body, usually with rounded ends, but sometimes showing dis- 
tinct branches. Is about 1.5 to 3.5 //. long, by 0.25 /i wide. 
Is found in sputa and in the lesion of tuberculosis. Is the 
cause of all forms of tuberculosis in man and may be trans- 
mitted to many of the lower animals. Is still unsettled 
whether the forms found in animals are capable of being 
pathogenic to man. 

Staining is difficult, but after having once taken it up the 
organism is with difficulty decolorized. Use Ziehl-Neelson 
or Gabbett's method. Stains by Gram's. 

Culture. — Blood-serum, glycerin agar-agar, potato, and 
glycerin bouillon. Growth is slow, best at 37° C, none 
when below 29° C. or above 42° C. Growth is dry, lusterless, 
coarsely granular, wrinkled, and slightly yellowish. 

Pathogenesis. — Tuberculosis results from the success- 
ful invasion of the B. tuberculosis. This may take place 
by means of: (i) the respiration; (2) the blood circulation; 
(3) lymphatic channels; (4) by ingestion. After having 
gained entrance it may give metastases by any of the first 
three, by continuity of tissue, or by direct im|)lantation. 

The characteristic lesion is the miliary tubercle. It is a 
small area of inflammation and degeneration resulting from 
the action of the bacillus. When the organism enters a suit- 
able location it undergoes multiplication. In a short time 

169 



lyo A MANUAL OF PATHOLOGY 

their number and the products of their metabohsm bring 
about an increase in the number of fixed connective-tissue 
cells, epithelioid cells. These cells are the first to appear. 
A Httle later, through the chemotactic effect of the bacteria, 
lymphoid cells escape from the blood-vessels. According 
to which cell predominates, the tubercle may be cither cpi- 
Ihelioid or lympJioid. 

As the bacteria multiply more nutrition is required, but 
this variety of inflammation is peculiar in that not only no new 
blood-vessels are formed but the pre-existing ones are de- 
stroyed as the process advances. Consequently the central 
area undergoes degeneration and coaguliition necrosis. 

The tubercle may be 

^ \ ^ > V divided into three zones, 

v., *^x t 1 "^v^^ according to its histologic 

^ ' ^ .^ X characteristics: (i) A. 

^\{:\ central zone containing 
l.^<^ f 5^- "^^ degenerated tissue cells 

\ ^ ^ ^ and bacteria. (2) A mc- 

are 



^^ ^ lUan zone, in which 



, -i -K 



^ ,\V " many epithelioid cells and 

^ ' ' ^^ ' •- \ frequently giant cells con- 

^ ^ "^ \ "• ' ' taining vesicular nuclei 

Fig. 75.-TuBERrLE Bacilli in Sputum arranged peripherally and 
(Ziegler). radially. (3) A periph- 

eral zone, in which are 
found a few epithelioid and many lymphoid cells. 

The giant cells as well as the epithelioid may come from 
the endothelium of the blood-vessels or lymph-vessels, from 
fibroblasts or from escaped leukocytes. 

If the process has been rapid the lymphoid cells usually 
predominate. If the individual's resistance is fairly good, 
some of the epithelioid cells may be converted into fibrous 
tissue. When resistance is marked, the tubercle may become 
encapsulated by fibrous tissue and eventually become infil- 
trated by lime salts. This occurs only where the resisting 
power of the patient becomes greater than the destroying 
ability of the organism. 



1 



THE SPECIFIC GRANULOMATA 17I 

As, however, the bacilh keep continually multiplying the 
tendency of the disease is to extend. This occurs by the 
organisms being carried into the lymphatic channels either 
directly or by the action of phagocytes. The latter may 
carry and deposit them in a neighboring lymph-gland where 
secondary lesions will occur. Metastasis may also take place 
by the organisms gaining entrance into a vein, entering the 






Fig. 76. — Subacute Tuberculosis of a Lymph-gland, X 70 (Durck). 
I, Thickened capsule; 2, caseous centers of the tubercles. At the peri- 
phery of the gland the tubercles are still discrete, and between them lies 
lymphadenoid tissue. In the center of the gland the nodules have formed 
larger confluent areas. Numerous giant cells. 



general circulation and setting up a more or less widely 
diffused general miliary infection. 

Recovery from tuberculosis is more common than is gen- 
erally beheved. According to post-mortem examinations, 
20 per cent, of the cases of tuberculosis recover. In such 
cases there is present the ability of the individual to resist 
the inroads of the process. The tubercle bacilli become 



172 A MANUAL OF PATHOLOGY 

encapsulated in a mass of connective tissue that prevents 
their further growth and extension. This new-formed tis- 
sue tends to contract and causes the broken-down portions 
to be absorbed, or else calcareous infiltration takes place. 

These walled-off areas are, however, still a source of dan- 
ger. Although tubercle baciUi do not form spores, yet 
infection may take place years after the connective- 
tissue growth, if for any reason the contents happen to escape. 

When it remains quiet it is called "latent" tuberculosis. 

The symptoms seen are probably due in a great part to 
the presence of associated pyogenic organisms, as no impor- 
tant toxic body has ever been obtained from the bacillus. 
The night-sweats, fever, and loss of weight seen in cases of 
pulmonary tuberculosis are due to the associated bacteria. 
There is generally present some anemia, and many authors 
claim that there is an increase in the number of lymphocytes 
in the blood. 

The liver frequently shows marked fatty infiltration and 
sometimes amyloid degeneration to a slight or a marked 
degree. 

The most common entrance for infection is the respira- 
tory system. Sputum from tubercular patients becomes 
dried and comminuted; it is then carried about by the cur- 
rents of air and enters the body. 

The intestines may become secondarily involved through in- 
fection brought about by swallowing the tubercular sputum. 

Congenital tuberculosis may come from the paternal side 
from infection of the genitals; from the maternal side 
through infection of an ovum, or it may be transmitted 
through the placenta. Heredity is no longer thought to 
have much direct influence. It is now believed that what 
is inherited is nothing more than a weakened resisting power. 

LEPROSY 

Leprosy is a chronic, specific, infectious inflammatory dis- 
ease caused by the B. leprae; which is a non- motile, non- 
sporogenous, acid-resisting, purely parasitic organism. Is 
pathogenic only for man. Is very slightly contagious. Is 



THE SPECIFIC GRANULOMATA 



173 



/: 






■^^M 



stained with 'some difficulty. Stains by Gram's. It cannot 
be grown on artificial media. 

It occurs most commonly in warm climates and in people 
of almost any age. Is most common in males of from 
twenty to thirty years. It is probably not hereditary, but 
children under three years have been affected. 

The bacilh are distributed to an extraordinary extent in 
the body of the leper, and in many cases there will be no 
inflammatory reaction in their neighborhood. They may be 
either extracellular or intracellu- 
lar, and in the latter case may be 
found in giant cells or lepra cells. 
These may contain numerous nu- 
clei and numbers of vacuoles as 
well as bacteria. 

The secretions of the mucous 
membranes of the nose usually 
contain great numbers of the 
bacilli. 

Varieties. — Two forms are 
commonly met with, the nodular 
and the anesthetic or nerve lep- 
rosy. It is seldom, however, that 
a quite pure case of either is 
found ; the majority belong to the 
mixed form. In the nodular va- 
riety the node may be preceded 

by a hyperemic patch which leaves behind it a ]:>igmented 
area. The nodules appear first in the skin and subcutaneous 
tissue of the face, and may remain single or become confluent. 

Macroscopically the nodes are rather grayish or yellowish. 
Microscopically they are composed of great numbers of 'small, 
frequently vacuolated epithelioid cells with also connective- 
tissue cells. These lesions are more vascular than those of 
tuberculosis, and consequently do not tend to undergo coag- 
ulation necrosis. Caseation does not take place and the ulcer- 
ation that is so common depends largely upon injuries and 
secondary infections. 



Fig 



77. — Giant Cell from 
A Leprous Ulcer of the 
Epiglottis, showing the 
Lepra Bacilli Scattered 
through the Tissue and 
Enclosed in a Large 
"Lepra Cell" (Lchmann 
and Neumann). 



174 



A MANUAL OF PATHOLOGY 



The nodules are found in other parts of the body, as on the 
back of the hand, — palm is not usually involved, — in the mu- 
cous membrane of the eye, nose, mouth, larynx, and intestine. 

The lymph-glands in both varieties are swollen, hard 
from connective-tissue formation, and yellowish on account 
of fatty degeneration. 



Ancsthclic leprosy is characterized by 



the growth of the 




bacilli in the sheath of the nerves and an increase in the 
connective tissue along their course. Is most common on 
the ulnar and popliteal nerves. There then appears neu- 
ritis wnth localized hyperemic spots. These become anes- 
thetic and in some cases become the seat of a blister. Finally 
ulceration may develop with the subsequent loss of the fin- 
gers or toes. 



THE SPECIFIC GRANULOMATA 1 75 

Many of the enlarged glands may be the result of a sec- 
ondary tuberculosis occurring late in the course of the 
disease. There is frequently fever and also nephritis. 
Amyloid degeneration is not uncommon in the ulcerative 
forms. 

The majority of the cases last from five to twenty years, 
usually dying of tuberculosis. 






> 



sAi 



Fig. 79. — Macular Lesions in Leprosy. 

GLANDERS 

Is a specific infectious disease of horses that is sometimes 
seen in man as the result of accidental infection. 

Is caused by the Bacillus mallei, a non-motile, non-spor- 



176 A MANUAL OF PATHOLOGY 

ulating, aerobic or optionally anaerobic bacillus. Is path- 
ogenic for man and lower animals. Stains by ordinary 
metliods, but not by Gram's. 

It makes its appearance in the membrane of the nose 
in horses in the form of small nodules the size of a pea. 
These may increase in size, but eventually break down and 
ulcerate with the formation of irregular ulcers, having yel- 
lowish, elevated, and indurated borders from which some 
bloody pus is discharged. Lymph-glands become enlarged. 




Fig. So. — Bacillus Mallei, from a Culture upon Glycerin Agar-agar 
X 1000 (Frankel and Pfeiffer). 



and metastatic abscesses may result. The lungs are fre- 
quently involved. 

Microscopically the nodules consist of masses of small 
round cells and epithelioid cells. Do not find giant cells. 

If the skin is involved the condition is known as ''farcy," 
and the nodules as "farcy buds." They generally undergo 
marked and extensive ulceration. 

Man may become infected through lesions of the mucous 



THE SPECIFIC GRANULOMATA 



177 



membranes of the eye or nose or of the skin, and the result is 
usually fatal. 

ACTINOMYCOSIS - 

Is a chronic contagious disease of cattle, but is sometimes 
found in man. 

Is caused by a fungus, the Actinomyces bovis, which is 
large enough to be seen by the naked eye, appearing as small 
yellow particles. The fungus is made up of a central mass 
of granular substance in which are many structures resem- 
bhng chains of cocci or 
spores. Extending from 
this center are many my- 
celial threads termi- 
nating in club-shaped 
extremities. Is both 
aerobic and anaerobic 
in its growth; the latter 
form alone being path- 
ogenic. Will grow on any 
artificial media. 

Stains yellow with pic- 
ric acid, red with picro- 
carmin, blue with anilin 
gentian and by Gram's. 

The infection is su])- 
posed to take place by 
means of spores gaining 

entrance into the human system by means of food, or by in- 
halation. Probably enters by way of decayed teeth. 

Where the fungus lodges there is a formation of nodules 
which break down, form abscesses, and discharge a creamy 
pus containing yellowish granules; which show the char- 
acteristic rayed appearance when looked at under the micro- 
scope. 

The neighboring bones may become riddled and there 
may also be metastatic growths in other organs, particularly 
the lungs. In the latter extensive necrosis may occur and 
the fungus will be found in the sputum. 



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Fio. St. — Actinomyces Cluster show- 
ing Radial Striations at Periphery 
(Karg and Schmorl). 



178 



A MANUAL OF PATHOLOGY 



Instead of breaking down connective tissue may be formed 
and encapsulate the invaded area. 

The characteristic lesion is the formation of embryonal 
connective tissue and granulation tissue. 

MYCETOMA 

Mycetoma or Madura jool is a chronic specific inflamma- 
tory condition caused by the Actinomyces madurce. This 
organism closely resembles the A. bovis, but the club-shaped 




Fig. 82. — .\CTiNOMYCES OF Madura Foot (Wrighl and Brown). 

Ciranule crushed beneath a cover-glass, showing radial strialions in the 

hyaline masses. Preparation not stained; low magnifying power. 



extremities are absent and spores may occur along the 
threads. Can be grown artificially, stains by the ordinary 
methods and by Gram's. 

Usually attacks the feet. A nodule slowly appears and 
in the course of a year or two may soften and discharge 
a thin pus in which are found minute rounded bodies resem- 
bling fish roe. These bodies may be either pinkish in color. 



THE SPECIFIC GRANULOMATA 1 79 

the pale or ochroid variety, or black like gunpowder, the 
melanoid form. 

On account of the degeneration numerous sinuses may 
form. The disease is painless and seldom fatal. 

MYCOSIS FUNGOIDES 

Is a rare infectious disease of the skin and mucous mem- 
branes, possibly due to a protozoa, but the true cause is not 
known. 

It makes its appearance as an erythema or eczema with 
the subsequent formation of a node below the surface. 
This node is quite red, hard, and sometimes painful. Soft- 
ening at the top of the nodule takes place with extensive 
ulceration and the escape of a clear or blood-stained fluid. 
The appearance is said to resemble that of a tomato. There 
is seldom any attempt at healing, the ulcer increasing in 
size. 

Microscopically there is found a marked formation of 
granulation tissue about the new-formed blood-vessels. Are 
numerous lymphocytes, epithelioid, and small giant cells. 
The poor blood-supply is probably the cause of the soften- 
ing and ulceration, 

MOLLUSCUM CONTAGIOSUM 

Is probably a parasitic disease of the skin, as it is undoubt- 
edly contagious, often occurring in small epidemics. 

On the skin are found numerous papular or warty nodules 
about the size of a pea, later becoming larger, with a central 
saucer-like depression due to degeneration. 

Microscopically the growth is made up of degenerated epi- 
thelial cells and small oval bodies, that may be cither intra- 
cellular or extracellular. Each lesion is made up of a num- 
ber of conical lobes converging toward a central opening. 
The cells may undergo an extreme cornification. 

The peculiar transparent oval bodies are by some con- 
sidered to be sarcosporidia, but the majority hold that they 
are degenerated epithelial cells. 



l8o A MANUAL OF PATHOLOGY 



RHINOSCLEROMA 

Is a chronic infectious disease of the skin and of the nasal 
mucous membranes. Probably due to the Bacillus rhin- 
osclcromalis. 

The disease occurs in the form of small firm nodules 
made up of a dense cellular infiltration of the corium and 
papillary layer of the skin. New connective tissue continues 
to form and frequently a hyaline degeneration occurs. 

The bacilli are found in the nodes either intracellular or 
extracellular. 

SYPHILIS 

Is a specific, infectious, and very contagious disease of 
man. Has never been observed in any of the lower animals 
except in the anthropoid apes. 

Its etiology is uncertain, is possibly due to Lustgarten's 
bacillus, one that quite closely resembles the tubercle ba- 
cillus. More recently a spirillum, the Spirochccta pallida^ has 
been so constantly found in syphilitic lesions that it seems 
very probable that that organism is the causative factor. 

The disease may be divided into the: 

1. Period of primary incubation, about three weeks. 

2. Period of primary symptoms, chancre and adenitis. 

3. Period of secondary incubation, about six weeks. 

4. Period of secondary symptoms, from one to three years. 

5. Intermediate period of two to four year s, during which 
the patient may recover^ ;. ' - / ' ^ ^h' 

6. Period of tertiary s3*mpt'oms, unlimited. 

The primary lesion is the chancre, which starts as a 
single papule, seldom multiple, at the seat of inoculation, 
which may be either genital or extragenital. This soon 
becomes eroded, but increases in size due to infiltration of 
the deeper tissues. The base becomes hard, and the surface 
is cither dry or is covered by a slight false membrane. 

Histologically there is an infiltration of round cells, par- 
ticularly along the vessels. Polymorphonuclear leukocytes, 
lymphocytes, plasma cells, endcthehal and connective-tis- 



THE SPECIFIC GRANULOMATA l8l 

sue cells, and fibroblasts are present. The blood-vessels 
undergo an arteritis, the endotheHum is increased in thick- 
ness, and obstruction may occur. There is also frequently 
a hyahne change in the vessels. 

The secondary lesions are first a swelhng and indura- 
tion of the neighboring lymph-nodes. There then appears 
a skin eruption accompanied by fever, constitutional symp- 
toms, and a rapid decrease in the erythrocytes, with a mod- 
erate leukocytosis, usually of the lymphocytes. The skin 
lesions are generally symmetric, do not itch, and are coppery 
in appearance. May be some loss of hair. 

The mucous patch or condyloma latum appears on the 
mucous membrane. It is a slightly elevated, moist, gray- 
ish lesion, covered by a thin pseudo- 
membrane. In these there is round- 
cell infiltration of the skin with super- 
ficial necrosis. There may be one or fig. 83.— Upper Median 
more patches. Incisors in Heredi- 

Although the chancre and the sec- tary Syphilis (Cornil 

T . I'll • '"^"^ Ranvier). 

ondary lesions are highly contagious 

the mucous patch is probably the most .^.^^'''^''^^^''^^^ 

so. y^^^IiiJ 

The chief tertiary lesion is the wti^mJkJ^ 

gumma. It is found most commonly ^'%:^^:ST}}:^- 
in the bones, in the liver, lungs, nil and Ranvier). 
kidney, heart, and brain. The gum- 
ma is a nodular mass made up of granulation tissue in 
which arc numerous blood-vessels. It usually undergoes a 
caseous or other form of degeneration, and may ulcerate or 
undergo cicatrization. It is hard, dense, and elastic. 

The blood-vessels show an endarteritis which closes or 
narrows the lumen. The remains of broken-down cells and 
particles of fat are present and giant cells may be found. 

Hereditary syphilis may result from disease of the 
ovum, spermatozoon, or both, or it may be transmitted 
through the placenta after conception has taken place. 

The mother of a syphilitic child will be immune to the 
disease, although she herself shows no symptoms (CoUes's 
law). 



102 A MANUAL OF PATHOLOGY 

An apparently healthy baby born of a syphilitic mother 
cannot subsequently be infected by her (Prof eta's law). 

The fetus may die in utero and be aborted, the child may 
be born dead, or it may be alive but die shortly after birth. 

The primary lesion does not occur in the hereditary form, 
but the secondary and tertiar)^ manifestations may be evi- 
dent, such as skin eruptions and mucous patches or even 
gummata. 

The upper incisors of the second dentition are frequently 
conical and peg-shaped with deep notches at the free edge 
(Hutchinson's teeth). 

There also frequently occurs a "white" pneumonia, cir- 
rhosis of the liver, spleen, and pancreas, osteochondritis, and 
interstitial keratitis. 



CHAPTER XIV 
PARASITES 

A parasite is an organism that lives in or upon another. 
Many are harmless, but some of them are distinctly path- 
ogenic, as they live at the expense of the individual, to the 
detriment of its well-being. 

The body at whose expense the parasite lives is called the 
host. 

Parasites may be divided into the vegetable and the ani- 
mal varieties. 

Parasitic diseases are characterized by having a specific 
exciting cause and by the fact that they can be transferred 
from one individual to another. Some forms go through 
a portion only of their life history as parasites. 

Others are able to Hve without the host and are known 
as optio7ial parasites. To this class belong many of the 
insects. 

Some cannot live independently and are known as obliga- 
tory parasites, such as the tapeworms. They have no sense- 
organs, ahmentary tract, or circulation. They have no 
need of such structures, as their food is taken up by absorp- 
tion. The organs by which they retain their grasp and 
their powers of reproduction are well developed. 

Pathologic conditions due to parasites may be the result 
of mechanical or chemical phenomena. 

Mechanical, as obstruction of the lumen of an intestine, 
vessel, or duct; hemorrhage resulting from bites and suc- 
tion, pressure. 

Chemical: disturbances resulting from the absorption by 
the host of poisons, or from degenerative processes, causing 
reflex nervous symptoms, inflammation, and irritation. 

183 



184 A MANUAL OF PATHOLOGY 



ANIMAL PARASITES 

Protozoa. 

Amoeba coli. 

Amoeba dysenterkT. 

Coccidium oviforme. 

Trichomonas intestinalis. 

Cercomonas intestinalis. 

Trichomonas vaginahs. 

Plasmodium malarias. 

Yellow fever. 

Trypanosomcs. 

Pyrosoma. 
Flat-worms. Platyhelminthes. 
C est odes. Tapeworms. 

Taenia solium. 

Taenia saginata or mcdiocanellata. 

Dibothriocephalus latus. 

T^nia echinococcus. 

Taenia nana. 

TcTnia cucumerina. 
Trematodes. Sucking worms. 

Distoma hepaticum. 

Distoma lanccolatum. 

Distoma haematobium. 

Distoma pulmonale. 
Nematodes. Round-worms. 

Ascaris lumbricoides. 

Oxyuris vermicularis. 

Eustrongylus gigas. 

Filaria medinensis. 

Filaria sanguinis hominis. 

Uncinaria duodenalc. 

Uncinaria americana. 

Anguillula intestinalis. 

Trichina spiralis. 

Tricocephalus dispar. 



PLATE II. 




Malarial Parasites in Blood (Grawitz). 
Numerous pigmented parasites, spore formation of the tertian type, and two 

crescents. 



PARASITES 



1B5 



PROTOZOA 

Amoeba Coli. — Probably two varieties, Amceha coli com- 
munis^ non-pathogenic, and the Amceha coli dysenteries, the 
cause of dysentery. 

Is found in the intestines, and in secondary abscesses, 
particularly of the Hver. 

Is a single spherical cell about 20 to 30 /Jt in diameter. 
Has no distinct membrane; each cell contains a nucleus 
and usually several vacuoles. The protoplasm is finely 
granular, frequently contains red cells and bacteria. The 







Fig. 85. — Amceba Coli in Intestinal Mucus, with Blood-corpuscles 
AND Bacteria (Losch). 



ameba is capable of moving by means of pseudopods. 
Ulceration of the intestine with perforation may occur. 
Sometimes find encysted forms. 

Coccidium oviforme is an eUiptical parasite that is 
rarely found in the intestines and liver of man but is com- 
mon in rodents. It has a distinct double capsule, is found 
within cells in which it undergoes rapid division. Fre- 
quently becomes encysted, and when taken into the intes- 
tine the capsule is dissolved and the organism is set free. 



1 86 A MANUAL OF PATHOLOGY 

Other less important parasites are the Paramoecium 
coli, an ovoid, unicellular organism about 7 to 10 microns 
long. Is surrounded by short cilia. Usually contains 
numerous large vacuoles. Is found in diarrheal feces. 

The Trichomonas intestinalis is a pear-shaped organism 
about 10 to 15 microns long. On one side ithasanundulating 



.^'x^ 






/;^;^>>4lft•^^^^■$^;•^y_^ 



\M 



.i.SV 



/ '•^- 



t'Si-:-: 



1^-..- V 









Fig. 86. — Coccidiosis of Rabbit's Liver (McFarland). 
Section of one of the affected bile-ducts, showing the papillary out- 
growths from the mucous membrane and the signs of inflammation in the 
surrounding tissue. 



membrane provided with about 10 to 12 ciha. Is found in 

intestinal discharges in diarrhea, typhoid fever, and cholera. 

The Cercomonas intestinalis is a pear-shaped para- 



PLATE I. 

3 4 









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n 



ts 



CD 



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16 



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19 



20 



2J 



22 



23 



24- 



25 

M 



26 



27 



PLATE I. 

Various Forms of Malarial Parasites (Thayer and Hewetson). 

Figs. I to TO, inclusive, tertian organisms; Figs, ir to 17, inclusive, 
quartan organisms; Figs. 18 to 27, inclusive, estivo-autumnal organisms. 

Fig. I. — Young hyaline form; 2, hyaline form with beginning pigmenta- 
tion; 3, pigmented form; 4, full-grown pigmented form; 5, 6, 7, 8, segment- 
ing forms; 9, extracellular pigmented form; 10, flagellate form. 

Fig, II. — Young hyaline form; 12, 13, jjigmented forms; 14, fully-de- 
veloped pigmented form; 15, 16, segmenting forms; 17, flagellate form. 

Figs. 18, 19, 20. — Ring-like and cross-like hyaline forms; 21, 22, pig- 
mented forms; 23, 24, segmenting forms; 25, 26, 27, crescents. 



PARASITES 187 

site about 10 to 12 microns long. From its blunt end extends 
a single flagellum. 

The Trichomonas vaginalis is an oval organism about 
10 microns long. To one end are attached three long fla- 
gella, near the base of which is an undulating membrane 
provided with five to six cilia. 

It has been found in the urine as well as in the vagina. 

The Plasmodium malariae is a unicellular parasite that 
during one cycle of its existence fives in the blood and brings 
about a destruction of the erythrocytes. Its other cycle is 
carried on within the body of a mosquito, the Anopheles. 

There are three varieties of the organism: 

1. The quartan parasite attains its development in three 
days. It appears inside an erythrocyte as a small, un- 
pigmented, irregular, hyaline body capable of slow ameboid 
movement. It grows gradually and brownish or black gran- 
ules appear. The erythrocyte becomes gradually paler and 
is finally completely filled by the plasmodium. 

The pigment occupies the center of the cell and later 
the parasite splits up into from six to twelve pear-hke seg- 
ments which, along with the pigment, escape into the circula- 
tion. Is the rosette form. The granules in this form are 
larger and darker than in the tertian, but not so numerous. 

Double infection may occur, in which case there would 
be paroxysms for two days, then an intervening free day. 

2. The tertian parasite requires two days for its develop- 
ment. In its early stages it resembles the quartan para- 
site, but it eventually becomes larger. The tertian con- 
tinues growing till it may be double the size of the red cell, 
the pigment particles collect in the center, and the organism 
divides into fifteen to twenty small, round, spore-hke bodies, 
resembling a bunch of grapes. This form of parasite con- 
tains more granules than the quartan, but they arc smaller 
and the red corpuscle is rapidly decolorized. 

3. The cBstivo-autumnal parasite is probably a tertian 
form. Is sometimes spoken of as mafignant tertian. 

The cycle of development lasts forty-eight hours. The or- 
ganism is smaller than in the first two, but more active. When 
fully developed it is about one-third the size of the red cell. 



168 A MANUAL OF PATHOLOGY 

When at rest it assumes the signet-ring form, a disc with 
a colored outhne. The pigment is very fine and hard to 
recognize. Is more marked in fresh specimens. 

The organism finally becomes lobulated, rosette-shaped 
with the pigment in the center or toward the periphery, 
and divides into six to twelve little balls. 

The development of this form seldom takes place in the 
peripheral blood, usually in the spleen, bone-marrow, and 
cerebral capillaries. 

The erythrocytes tend to shrivel and become dark. In 
this variety of infection are found the crescents of Laveran. 
They are oval or crescentic bodies that are pigmented in 
their center and have no ameboid motion, but are able to 
slowly alter their shape. 

When fully developed are larger than a red cell. They 
are found partly in red corpuscles, or clinging to them, 
free in the blood and sometimes in leukocytes. Occur only 
in the severe forms of malaria; are probably malignant 
tertian parasites that have failed to sporulate. 

Flagellated bodies are found in all forms of malaria. 
They are small, spherical, pigmented bodies, about the size 
of an erythrocyte. They lie free in the blood and have 
from one to four long, dehcate, actively motile flagella. 

This form is not seen immediately after the removal of 
the blood, usually does not appear for some fifteen minutes. 

They originate from the large pigmented spheres that 
have not sporulated, and represent the form of parasite that 
propagates the species outside the human body. 

DIFFERENCES BETWEEN THE PARASITES. 

Quartan. Tertian. .^stivo-autumnal. 

Cycle three days. Forty-eight hours. Forty-eight hours. 

Ameboid motion sluggish. Rapid. Brisk. 

Red cell slowly decolorized. Rapidly. Cell becomes darker, 

bronze-like. 

Little change in size of red Aluch swollen. Cells small and shriv- 

cell. eled. 

Parasite sharply outlined. Indefinite. Faint. 

Pigment granules coarse Fine and numerous; Granules fine, not 

and few, and in rapid in motion. often in motion. 

motion. 

Spores six to twelve, large Fifteen to twenty, Six to twelve small 

and pear-shaped. small, round. spheres present. 



PARASITES 



When the organisms sporulate and are set free within 
the blood the fever rises and the chill takes place. The 
escaped spores enter other red corpuscles, go through the 
same cycle, and a continuous reinfection occurs. 

The foregoing cycle is the asexual one that takes place 
within the human body. It is now definitely settled that 
infection takes place by means of the bite of a special va- 
riety of mosquito, the Anopheles. Of mosquitos, only the 
female bites. 

This insect withdraws the malarial parasites from an 
infected individual, they undergo further stages of develop- 
ment, and are again transmitted to other people by the 
mosquito biting. 

In the blood of an infected person two chief forms of par- 
asite are found. One that is the smaller is round and con- 
tains numerous granules and is called the microgametocyte. 
From it flagella are given off. These flagclla penetrate a 
larger spherical form that has a clear protoplasm, the macro- 
gametocyte; the former being the male, the latter the female 
element. The impregnated parasite is called a zygote. 
These zygotes penetrate the stomach and become attached 
to the outer wall, where they grow much larger and are 
called s^orozoons or meres. They finally undergo division 
into secondary spheres which ultimately split up into very 
many small spindle-like bodies known as sporozoitcs or 
blasts. These escape into the body cavity of the mosquito 
and the majority finally gain entrance into the salivary 
glands, from which they escape in the secretions. 

When the blasts gain entrance into the blood they attack 
the red corpuscles and give rise to malaria. 

In this case the mosquito is the definitive host of the par- 
asite, man the intermediate. 

The cycle of development in the mosquito takes from 
eight to ten days. 

The following is a description of the Anopheles mosquito. 
Palpi in both sexes nearly as long as the proboscis, 4 jointed 
in female, 3 in male. Is a constricted basal joint in each. 



190 A MANUAL OF PATHOLOGY 

Palpi are straight and parallel with proboscis except when 
female is biting, when they diverge. 

Nucha has scaly posterior cornu, abdomen hairy on both 
surfaces, not scaly. Legs long and end in simple dentate 
claws. Wings spotted, and these spots when magnified 
are seen to be made up of black squamae on brownish wing. 

Length of female 7.5 to 9 mm., including proboscis; 
male smaller and does not bite. 

When resting on a perpendicular wall the Anopheles 
extends its body at right angles unless it is filled with blood, 
the Culex holds its body parallel. 

Yellow fever is an infectious disease, probably caused 
by some protozoon which is carried by a mosquito, the 
Stegomyia jasciata. 

The female mosquito is from 3.5 to 5 mm, long, head 
clothed with flat scales, black and gray on each side. A 
white patch in the middle in front, extending back to the 
neck. A white patch on each side and thin white borders 
to the eyes. Antennae blackish with narrow pale bands. 
Last joint of palpi white on inner side. Thorax dark 
brown, ornamented with white curved band on each side 
of the back and white spot on each side in front. 

Abdomen dark with basal bands of white. 

Fore- and mid-ungues toothed, hind ones not. 

This mosquito may convey yellow fever to a non-immune 
as early as on the twelfth day after biting an infected person, 
and it may retain the power to do so as long as it Hves. 

This disease can also be transmitted by the hypodermic 
injection of blood drawn from a patient in the first, second, 
or fourth days of the disease. It cannot be communicated 
by fomites. 

The infected agent can be passed through a filter that is 
impermeable to ordinary bacteria and is destroyed by a 
temperature of 55° C. maintained for ten minutes. 

One attack usually renders a person immune. 

Trypanosomes are elongate spindle-shaped organisms, 
a little longer than the diameter of a red corpuscle. One 
end terminates in a long flagellum. These bodies are found 



PARASITES 



191 



in the blood in certain diseases of the lower animals, as 
"nagana" or tse-tse fly disease, or in "surra." 

Recent investigations have shown the presence of try- 
panosomes in the cerebrospinal fluid of people suffering 
from "sleeping sickness." 

Except in "dourine, " in which the disease is transmitted 
among animals by coitus, a biting fly is the carrier of the 
infection. 

Texas fever is an acute febrile disease of cattle result- 
ing from the presence in the blood of the pyrosoma bigem- 




FiG. 87. — Trypanosoma, showing Multiplication by Division (from 

Laveran). 
;/, Nucleus; c, centrosoiiu'; ///, undulating membrane; /, ilagellum. 



inuni. Is a small pear-shaped organism found within the 
red cells. In this disease the common cattle tick is the 
means by which it is spread. This parasite is pecuHar in 
that it passes into the eggs of the tick and infects the 
embryos. 

Montana spotted fever is a peculiar acute febrile dis- 
ease found in a certain part of Alontana and supposed to 
be caused by a blood parasite resembling the pyrosoma 
of Texas fever. Is thought that it is transmitted by wood- 
ticks that have flrst obtained blood from a variety of squirrel. 



192 



A MANUAL OF PATHOLOGY 



WORMS 

Cestodes or tapeworms are more or less elongated, 
flattened, and segmented bodies that attach themselves to 
the mucous membrane of the intes- 
tine by means of suckers or hook- 
lets. 



-'v^^^^*^*^?^ 





Fig. 88. — Head of T.enia So- 
lium (Hosier and Peiper). 



Fig. 89. — Mature Seg- 
ments OF T^NiA So- 
lium (M osier and 
Peiper). 



They have no alimentary canal. Are hermaphroditic. 
One cycle of their life-history is in man, the other in some 





Fig. 90. — Eggs of T^nia Solium (Mosler and Peiper). 



one of the lower animals. The fully developed v^orm is 
called a strobile. It consists of a head, a very narrow neck, 
and a number of segments called proglottides. These seg- 




Fig. 91. — T^NiA Solium 
(Mosler and Peiper). 





Fig. 92. — Head of T.enia Sagi- 
NATA (Mosler and Peiper). 




P'lG. 93. — Mature Segments 
OF T-enia Sag I NAT a 
(Mosler and Peiper.). 




Fig. 94. — Eggs of T^nia Saginata (Mosler and Peiper). 
13 193 



194 



A MANUAL OF PATHOLOGY 



ments complete or the eggs from them escape in the feces. 
They are then taken up in the food, the covering of the egg 
digested and the embryos penetrate the tissues, ultimately 
lodging in the voluntary muscles and elsewhere. The em- 



IpTTrmiTlllllllll 





OmffllDID 



rrninxa 




Fig. 95. — T.i;nia Saginata (Eichhorst). 

bryo worm when lodged in the tissues is called a scolcx, 
and is surrounded by a bladder-like body known as a cys- 
ticerciis. When the animal food is eaten the embryos are 
set free, and attach themselves to the intestine. 





Fig. 96. — Head of Dibothriocephalus 

Latus (Blanchard). 

a, a, Bothridies; h, neck. 



Fig. 97. — Ripe Seg- 
ments of Diboth- 
riocephalus 
Latus (Mosler 
and Pcipcr). 



Taenia solium, or pork tapeworm, is usually about 3 meters 
long. The head has a rostcllum armed with a double row of 
from 26 to 30 booklets and four suckers on the sides. The 



PARASITES 



195 



uterus consists of a median tube with from 6 to 12 coarse 
lateral tubes. The genital pore is on alternate sides of the 
segments, which when mature are longer than they are broad. 

The eggs are oval, about 30 to 35 microns in diameter, 
and consist of a peripheral striated zone and a central gran- 
ular portion in which can be seen six lines representing 
hooklets. The embryos occur in pork as measles, and as 
cysticercus cellulosai in the muscles, brain, and eye of man. 
They gain entrance in uncooked pork. 

The Taenia saginata or mediocanellata is the beef tape- 
worm. Is quite common. It varies in length from 4 to 
8 meters. Head is small, is flattened on the top, has no 
rostellum nor booklets. 

The uterus is hke that of T. solium, but possesses from 
20 to 30 lateral branches 
which frequently divide di- 
chotomously. The genital 
pore is on alternate sides of 
the proglottides, which are 
longer than they are broad 
when fully matured. The 
eggs are a little larger and 
more oval than those of T. 
sohum, otherwise very simi- 
lar. Results from the eating of improperly cooked beef. 

The Dibothriocephalus latus has for its host some kind of 
fish, usually the pike. It is the largest of the tapeworms, 
measuring from 5 to 9 meters in length and having at times 
as many as 4000 segments. 

The head is long, flattened, and has two groove-like 
suckers on its sides. The neck is thin, gradually increasing in 
diameter. 

The proglottides arc broader than long and the uterus, 
instead of being branched, consists of a tube coiled upon 
itself in the center. 

The genital pore is on the flat side of the segment, and 
always on the same side of the worm. 

The eggs are oval and possess a shefl-like cover which 





Fig. 98. — Eggs of Dibotiiriocepha- 
• Lus Latus (Moslcr and Pciper). 



A MANUAL OF PATHOLOGY 



has a hinged hd at one end. These eggs develop in fresh 
water into a freely moving, ciHated embryo that finally 
enters the digestive tract of the fish. 

The Taenia echinococcus in its adult form is found in 
the intestinal tract of the dog, the lar- 
val form occurring in man and some 
of the lower animals. 

It is quite short, about 4 or 5 mm. 
long, and consists of four segments. 
The head, which forms the first, is 
long, has four suckers and a rostellum 
having from 14 to 25 hooklets arranged 
in a double row. 

The fourth segment is the largest 
and constitutes about two-thirds of the 
entire worm. It alone possesses a 
uterus which consists of a median por- 
tion with a few lateral branches. It 
contains numerous long oval eggs with 
very thin shells. The eggs enter the 
intestine, the shells are dissolved and 
the embryos set free. They penetrate 
various tissues, particularly the liver, 
become encapsulated, and slowly de- 
velop into cysts whose walls are made 
up of two layers — the outer cuticular 
and the inner granulo-cellular layer. 

In the course of some weeks small 
projections grow from the inner layer 
and project into the primary cyst. 
These buds have hooklets and suckers 
and are embryo parasites. 

This variety of cyst is the echinococ- 
cus scoleci partus. 

In the echinococcus hydatidosiis or 

E. endogenes, daughter and even 

grand-daughter cysts develop inside the original cyst. They 

probably result from a cystic change in the buds already 





;a>, 



Wl 



Fig. 99. — DiBOTHRio- 

CEPHALUS LaTUS 

(Eichhorst). 



PARASITES 



197 



mentioned. Sometimes secondary cysts form on the outside 
of the wall, the E. exogenes. 

The echinococcus multilocularis is the variety in which 
there are a great many small cysts sur- 
rounded by dense connective tissue. 
These cysts contain pigment and cal- 
careous matter, but seldom scohces; arc 
usually sterile. 

These various forms of echinococcus 
cysts are filled with a clear fluid of about 
1009 to 1015 specific gravity; is neutral 
or alkaline, contains no albumin, but 
sodium chlorid is present and sometimes 
sugar. 

A cyst may become very large or the 
fluid disappear by absorption and inspis- 
sation. 

It may be harmless or dangerous ac- 
cording to its location. May undergo 
suppuration. 

Is usually found in the liver, but may occur in lungs, 
kidneys, spleen, omentum, and in the brain. 




Fig. 100. — T^NiA 

E C H I N O C O C- 

cus; Enlarged 
(M osier and 
Pciper). 




Fig. tot. — Df.velopmext of Ovum. X Qo(Lcuckart) 
a, Suspended heads; h, ])rimary rudinic 
d, intussuscei)tion of ha 



cnt of head; c, further development; 
d, intussusception of head; r, later budding. 



The Taenia nana, or dwarf tapeworm, is from 2 to 3 mm. 
long. Its head is rounded, has four suckers and a rostcl- 
[um that may be protruded or retracted, on which is a single 



1 go A MANUAL OF PATHOLOGY 

circle of from 22 to 27 hooklcts. Are about 200 segments, 
all of which are broader than long. 

The intermediate host is not definitely known; is thought 
to be some form of insect or snail. 

The adult form alone is found in man. It attaches 
itself to the intestine by sinking its head deep into the mu- 
cous membrane. 

The Taenia cucumerina or clliptica is the common 
tapeworm of cats and dogs. Is about 15 to 30 cm. long 
and has a head with a rostellum possessing 60 booklets 
arranged in four rows. The rostellum can be protruded 
or retracted. The junction of the proglottides is much nar- 
rowed. Each segment has two genital pores, one on either 
side. The intermediary host is probably the dog louse or 
sometimes the flea. 

Trematodes, or sucking wonns, are flattened elhptic 
organisms that possess a sucking organ at the head end and 
another on the abdominal surface behind the short neck. 
They are usually hermaphroditic, but in some the two 
sexes occur. 

The Distoma hepaticum, or liver fluke, is from 15 to 
35 mm. long and 6 to 20 in width. Is pointed bluntly at 
each end and has two suckers, one at the head, the other 
on the ventral surface. Between the two suckers is the 
genital pore. The eggs are oval, 0.14 mm. in length, and 
provided with a lid at one end. Is hermaphroditic, the 
genital pore acting as a common opening for both sets of 
sexual organs. MultipHcation takes place by the union of 
two parasites, each acting as both male and female. The 
adult parasite usually inhabits the bile-ducts of sheep, some- 
times of man, in large numbers. It may obstruct the biliary 
ducts, giving rise to congestion and enlargement of the liver 
with later on degeneration and cystic formation. A water 
snail may be the intermediate host. 

The Distoma lanceolatum is about 8 to 10 mm. long, 

2 to 2.5 mm. wide. The anterior end is the more pointed. 
Has two suckers, quite widely separated, and in between 
them is the genital pore. 



PARASITES 199 

The eggs are oval, about 0.04 to 0.05 mm. long. 

The snout has a spread-out membrane like an umbrella. 

Is frequently found in combination with the D. hepat- 
icum. Intermediate host unknown. 

The Distoma hematobium has two distinct sexual 
forms, the male and the female. 

The male is the larger, is from 12 to 14 mm. long and i 
mm. thick. The female is longer and thinner, 16 to 18 mm. 
long and 0.13 mm. thick. 

The eggs are oval, 0.12 mm. long, and somewhat pointed 
at the ends. 

In the act of fecundation the female crawls into a canal 
formed by the curving up 
of the sides of the male. 

These parasites occur 
in the portal, abdominal, 
and cystic veins. The 
eggs are produced in great 
numbers and obstruct 
and rupture the capilla- Fig. 102.— Human Blood Fluke (Schis- 
ries, thus escaping into ^^^^euckarT"' ''"""'""^"^• 

the tissues. The wall of ^^e female is partially within the canalis 
the bladder may become gynaecophoms of the male. 

inflamed, ulceration take 

place, and eggs and blood escape in the urine. 

The embryos are supposed to live in water and gain en- 
trance by the alimentary tract. 

The Distoma pulmonale is a form that has quite fre- 
quently been found in Japan and China. 

Is 8 to 10 mm. long, 5 to 6 mm. wide. Resembles cjuitc 
closely the liver fluke. 

Is found in the lungs, usually near the periphery of a 
cavity. These cavities contain a muco-purulent liquid in 
which are found many eggs. 

Nematodes, or round worms, are long round parasites, 
are not segmented, are provided with alimentary organs, and 
the sexes are separate. 




200 



A MANUAL OF PATHOLOGY 



The life-history, with the exception of the trichina, is com- 
pleted within a single host. 

The Ascaris lumbricoides is the commonest intestinal 
parasite in man. The female may be 40 cm. long and 5 to 
6 mm. thick; the male 25 cm. long and 2 to 4 mm. thick. 
The body is brownish and has four longitudinal ridges 

extending the entire length. The 
head has three rounded lips, be- 
tween which is the mouth. 

The alimentary canal runs 
through the entire worm to an 
opening on the hinder abdominal 
surface. 

The sexual organs occupy the 
posterior half of the body, the 
sexual opening being at the junc- 
tion of its anterior and middle 
thirds. The uterus is double, 
thread-like, and twisted; may 
contain millions of eggs, which 





Fig. 103. — Ascaris Lumbricoides 
(Female) (Mosler and Peiper). 



Fig. 104. — Eggs of Ascaris Lum- 
bricoides (Mosler and Pei- 
per). 



are from 0.05 to 0.06 mm. long, are oval, and are covered by 
a layer of clear albuminous matter which preserves them for 
a long time after being extruded. 

An intermediate host is not needed, the eggs developing 
in the human intestine. They may occur singly or in num- 
bers. x\re found in the small intestine, but may migrate, en- 



PARASITES 



20I 



terlng the gall-ducts, the stomach, the esophagus, and even 
the larynx or nasal cavities. 

May obstruct the intestine, or set up inflammation with 
perforation and abscess formation. Also cause obscure ner- 
vous symptoms. 

The Oxyuris vermicularis, Thread or Seat worm, is 
commonly found in children. 

Is white in color; the female is from lo to 12 mm., the 
male 2.5 to 5 mm. long. The tail of the female is long and 
tapering, that of the male blunt and curved upon itself. 
The mouth lies between three lips. The genital pore is ante- 
rior in the female, posterior in the male. The eggs are oval, 
about 0.005 ^^- long, and contain 
embryos with sharp posterior ends. 

The parasites live in the large 
intestine, usually in great numbers. 
May leave the rectum and enter the 
vagina and urethra in girls, causing 
much irritation and itching. The 
eggs are swallowed, hatch in the 
upper intestine, and the female 
worms becoming fecundated form 
more eggs. 

The Eustrongylus gigas is a 
large round worm found in the pelvis of the kidney or 
ureter, usually in horses or cattle, but sometimes in man. 
The female is about one meter long and 8 to 12 mm. thick, 
the male about one-third as long. Is reddish in color, the 
anterior end is retracted, and around the mouth are six 
papilLne. In the male the posterior end is expanded, and a 
spicule projects from the cloaca. 

The Filaria medinensis, or ''Guinea- worm," is a very 
slender round worm about one meter long. The female only 
is certainly known. It has a circular oral opening with 
four booklets. The tail is sharply pointed. 

The greater part of the worm consists of a uterus which con- 
tains enormous numbers of embryos. These escape, especially 
when water is brought in contact with the ulcer from 




Fig 



105. — Oxyuris Ver- 
micularis AND Egg 
(after Heller). 
a, Natural size; h, egg. 



202 A MANUAL OF PATHOLOGY 

which the worm extrudes. The embryos hve in the water, and 
one view is that a minute crustacean is the intermediate host. 

This worm is found in the tropics and occurs in the sub- 
cutaneous tissues, particularly of the feet and hands. 

The Filaria sanguinis hominis as commonly found is 
the embryo of a worm that is rarely seen in the adult form. 
The usual form is the Filaria nocturna. The adult is from 
8 to lo cm. long and lives in the larger lymphatic vessels. 
No eggs are laid, but great numbers of living embryos are 
set free in the lymphatics and thence into the blood. The em- 
bryos are about 0.25 mm. in length and the diameter a little 
greater than that of an erythrocyte. The head is broad and 
blunt, the tail tapering. They appear in the blood only during 








Fig. 106. — Filaria Embryo, Alive in the Blood (F. P. Henry). 

the period of rest. If the person works at night and sleeps 
during the day, they will be found during the latter period. 

They escape through the kidneys into the urine in attacks 
of hematuria. 

The mature worm, from obstruction to the lymphatics, may 
give rise to marked enlargements, such as lymph-scrotum 
and elephantiasis. 

The Filar ia-pcrstans is a form that is found in the blood 
at all times, day or night. The embryo alone is known. 
The Filaria diurna occurs in the daytime only. 

Filariasis is common in Egypt, India, and Africa, and the 
intermediate host is a mosquito, one of the Culex variety. 

The Uncinaria (Anchylostoma) duodenalis is a small 



PARASITES 



203 



round worm found in the upper intestine of man. The 
male is from 7 to 1 1 mm. long and 0.46 mm. wide, the female 
from 7 to 16 mm. long and 0.63 mm. broad. The head of 
the worm is cylindric and bends backward. The mouth has 
three pairs of sharp incurved booklets and opens directly 
into an esophagus that occupies the anterior third of the 
worm. 

The posterior end of the female is pointed and has two 
openings, the excretory and the genital pore. The tail of 



h a 




Fig. 107. — Uncinaria Duodenalis (von Jaksch). 

a, Male, natural size; h, female, natural size; c, male, magnified; d, female, 

magnified; e, head, greatly magnified; /,/,/, eggs. 



the male is expanded and is arranged like a three-leaved 
cup. 

The eggs appear in the feces as oval, thin-shcllcd, and 
doubly contoured bodies about 0.36 to 0.63 mm. long. The 
number of eggs is enormous. Has been estimated that more 
than four millions may occur in a single stool. After ex- 
posure to the air the embryos escape from the eggs in about 
six days and continue their existence in the water. They 
may gain entrance by means of drinking-water or, as has 
been shown, the embryos may penetrate the skin of the feet. 



204 



A MANUAL OF PATHOLOGY 



The adult worm may occur in small or large numbers. 
It attaches itself to the wall of the intestine and sucks the 
blood for its nourishment. If the worm lets go, there re- 

mains an area of ecchymosis 

with a small point of hemor- 
rhage in the center. It is 
thought that the parasite 
may inject into the wound 
some substance that inter- 
feres with the coagulation of 
the blood. 

If the organisms occur in 

great numbers, the loss of 

blood may be so severe as to cause a very marked anemia. 

This condition exists in Egypt, southern Europe, and Brazil. 

The Uncinaria americana is a closclv related worm that 




Fig. io8 



Trichocephalus Dispar 
(Heller). 
a, Female; ^,male (natural size). 




Fig. 109. — Eggs of Various Worms Found in the Alimentary Canal 
OF Man. X 400 (Mitchell). 
A, Ascaris lumbricoides; B, C, Oxyuris vermicularis; d, Trichocephalus 
dispar; E, Uncinaria duodenale; f, Fasciola hepatica; g, Dicrocoelium lan- 
ceolatum; H. Taenia solium; i, Taenia saginata; k, Dibothriocephalus latus. 



is widely distributed in America, particularly in the sandy 
soil of the Southern States. It has a much smaller head, 
smaller and blunter teeth, and is less dangerous than the 
European variety. 



PARASITES 



205 



The Anguillula intestinalis is a very motile worm, about 
2 mm. long, and very thin. Is found in the intestine. The 
embryos were thought to be a different form of parasite and 
were formerly called A. stercoralis. Occurs in China and 
is found in some cases of diarrhea. 

The Trichocephalus dispar, or "whip- worm," is found 
in the large intestine of man, but is of little pathologic im- 
portance. 

Is from 4 to 5 cm. long and is pecuHar in that the anterior 
two-thirds are very slender, while the posterior third is thicker. 
In the male the posterior portion 
is spirally coiled, in the female is 
shghtly curved. 

The eggs are about 0.55 mm. 
long and at each end have a but- 
ton-like excrescence. 

The Trichina spiralis is a very 
important parasite that undergoes 
development in two hosts. 

It occurs in tv/o forms in man 
and the lower animals, as an in- 
testinal fully developed worm and 
as an encapsulated embryo in the 
muscular tissue. Is most com- 
mon in hogs. The adult female 
is from 2 to 4 mm., the male 1.5 
mm. in length. The eggs develop 
into embryos while within the 

mother. When an encysted embryo is taken into the stomach 
the gastric juices dissolve the shell, and the parasite is set 
free. It very rapidly matures, and in the course of from five 
to seven days eggs are discharged. Within a few days a 
couple of thousand embryos will have been liberated. These 
young parasites penetrate the walls of the intestine, gain 
entrance either into the blood or the lymphatics, most pro- 
bably the blood, and in the course of about ten days become 
lodged in the voluntary muscles. 

In the muscle fibers the embryos become encysted in two 




Fig. 110. — Fresh Muscle 
TRiCHiN.i: (Moslcr and 
Pcipcr). 



206 A MANUAL OF PATHOLOGY 

to three weeks. There is a deposit of hme sahs around the 
curled-up embryos which may either die and become calci- 
fied or remain ahve for years. The encysted form appears 
as a small white point. 

Infection in man takes place by the eating of meat (measly 
pork) that contains the trichina:^ and that has not been pro- 
perly cooked. A temperature of 65° C. kills the parasite, 
but pickling and smoking destroy those only which arc in 
the superficial parts, those deep within being unaffected. 

When the embryos escape from the cysts into the intes- 
tine severe vomiting and diarrhea may occur. During the 
emigration to the muscles the symptoms are those of mus- 
cular rheumatism. In this disease there has frequently been 
noticed a very great increase of the eosinophile cells in the 
blood. 

ARACHNOIDEA 

The insects are external parasites which may prove dan- 
gerous by means of their own metabolic products, by acting 
the part of intermediate host for some parasite, or by 
mechanically carrying the source of infection. 

The first class is not very important. In the second is 
the mosquito, which may in some of its varieties transmit 
malaria, yellow fever, or filaria sanguinis hominis. 

Flies may mechanically convey typhoid bacilh from feces 
to articles of food. 



CHAPTER XV 
POST-MORTEM EXAMINATION 

The purpose primarily of post-mortems is to determine the 
cause of death. Frequently there are found several dis- 
eased organs. The question then arises as to the order in 
which they were involved and from what their condition 
resulted. 

The examination may be divided into the inspection of the 
external appearances and into the examination, both macro- 
scopic and microscopic, of the internal organs. 

During the post-mortem there should be some one to take 
notes on the various findings. If possible, the clinical his- 
tory of the case should be learned before the autopsy is begun. 

EXTERNAL INSPECTION 

The appearances should be carefully noticed, as they are of 
great importance, particularly in medico-legal cases, such as 
approximate age; sex; height, measured as the body lies 
on its back between two uprights; bodily development; con- 
dition of nutrition; general condition of the skin; amount 
of fat present. 

Distinguishing marks; irregularities of the teeth, deform- 
ities of any kind; fractures; wounds, whether ante-mortem 
or post-mortem. If the former, there may be indications of 
bleeding, edges will gape, and there will be some signs of 
inflammation or beginning repair. If post-mortem injury, 
there will be no escape of blood into the tissues, no bleeding 
on incision, no inflammation or repair. 

Presence of edema, most common in the lower extremi- 
ties at the ankles, the scrotum, and labia. 

Signs of decomposition, first appearing as a greenish dis- 

207 



208 A MANUAL OF PATHOLOGY 

coloration of the abdomen and prominence of the super- 
ficial veins due to the staining of the tissues by blood-pig- 
ment from degenerated erythrocytes. 

Rigor mortis, its degree and extent; post-mortem lividity, 
or hypostases, is present in dependent parts and disappears 
on pressure; diffuse pigmentation, the result of decomposi- 
tion, does not disappear on pressure. 

The condition of the pupils, whether dilated, contracted 
or unequal; the sclera; size and shape of thorax; disten- 
tion or retraction of abdomen. 

INTERNAL INSPECTION 

The generally accepted order of examination is brain, spinal 
cord, thorax, and abdomen. The brain should be examined 
first, so that the amount of blood in the cerebral vessels can 
be determined. As in this country autopsies are usually 
limited to the thorax and abdomen, they will be first des- 
cribed. 

The autopsy should not be done by artificial light, as the 
color values arc distorted. 

The operator should stand on the right side of the body 
and should grasp the handle of the knife as he would in cut- 
ting bread. The knife should be drawn and not pressed or 
shoved into the tissues. The main movement should come 
from the shoulder, the secondary from the elbow-joint. 

Incisions into organs should be deep and single rather 
than shallow and numerous, as a broad surface gives much 
more information than a narrow one. 

The primary incision is a long single one extending from 
the larynx along the median line to the pubes, passing to the 
left of the umbilicus so as to avoid the round ligament of the 
liver. The knife should be held almost horizontal so that 
the belly and not the point is used. 

Over the sternum the incision extends to the bone; over 
the abdomen it should go only as deep as the subcutaneous 
tissue or the muscle. The abdominal cavity is opened by 
making a small incision through the peritoneum a little below 
the xiphoid cartilage. Two fingers of the left hand are in- 



POST-MORTEM EXAMINATION 209 

serted, the flaps drawn upward, and the incision continued 
between them down to the pubes. The recti muscles may 
be divided just above the pubes, care being taken not to cut 
the skin. 

The abdominal flaps in turn are seized with the left hand 
and strongly drawn outward. This renders the tissues tense 
and they are dissected away from the ribs by long sweeping 
cuts. The operation begins over the lower border of the 
ribs and is carried up a little above the articulation of the 
clavicle and outward as far as the anterior axillary Hne. 

The abdomen should then be inspected, first without touch- 
ing anything. The organs and their relations should be noted ; 
the character and the amount of any fluid present and any 
that runs off should be caught and measured. The omen- 
tum should be removed and the intestines examined, also the 
appendix and the mesenteric lymph-nodes. The peritoneum 
normally is smooth, glistening, and transparent, the same as 
any serous membrane. 

The height of the diaphragm is determined by introducing 
the hand under the costal margin and finding at what rib or 
interspace it reaches in the mid-clavicular line. On the right 
side is usually about the level of the fourth rib or interspace, 
on the left is about the third rib or interspace. If lower than 
normal it generally indicates fluid in the pleural cavity, en- 
largement of the thoracic organ or new growths. 

Before opening the thoracic cavity, if pneumothorax be sus- 
pected raise the skin flap and fill the pocket thus formed with 
water. Puncture below the level of the water and watch for 
bubbles to come through. 

The thorax is opened by cutting through the costal carti- 
lages, from the second dowTi, by holding the knife almost hor- 
izontal and resting it on the rib in advance before the pre- 
vious one is completely severed. The division should take 
place at the junction of the rib and cartilage. Instead of 
using a knife the intercostal spaces may be first opened and 
the ribs then divided by means of the costotome. By this 
method there is less danger of cutting into the lungs. 

The sternum is elevated by grasping the xiphoid cartilage; 
14 



2IO A MANUAL OF PATHOLOGY 

the attachment of the diaphragm is divided on either side. 
It is freed from the underlying tissues by long cuts of the knife, 
which should be made close to the bone so as to avoid the 
pericardium. When the first rib is reached its cartilage is 
divided about 2 cm. further out than that of the second. The 
edge of the knife should be directed upward and outward, the 
handle being beneath the elevated sternum. 

The clavicle may be disarticulated by cutting from below 
along the irregular line of the stcrno-clavicular articulation. 
By this method there is less danger of wounding the large 
vessels at the base of the neck, a very important point in 
medico-legal cases. The articulation may be divided from 
above by entering a narrow knife along the line of the joint, 
which curves down and out. The handle of the knife should 
incHnc so that it is nearer the cadaver's chin than is the 
blade. If held perpendicular both the clavicle and sternum 
interfere, as the joint slants. If properly carried out, it can 
be done without any great force being exerted, short up and 
down strokes being used. The sternum should then be 
twisted out rather than cut, otherwise the large vessels of the 
neck may be divided. 

If the cartilages have become calcified, care should be taken 
not to cut one's hands on the exposed ends. Protection can 
be had by drawing the dissected flap of skin over the edges. 

If removal of the sternum is not allowed, the thoracic 
organs may be removed from below by separating the dia- 
phragm from the ribs. 

On removal of the sternum, the lungs and the pericardial 
sac are exposed. One should notice how near the lungs 
come to meeting in the median line. Ordinarily they will 
touch at the level of the second rib. 

The pleural cavities should be examined. One should 
determine the presence or absence of fluid, its character and 
amount. Adhesions should be looked for, and the amount of 
force required to break through them is a guide as to their 
duration. If the adhesions are very dense, the best way 
when one comes to remove the lungs is to strip off the costal 
layer of the pleura with the viscera. 



POST-MORTEM EXAMINATION 211 

In opening the pericardium the sac is picked up by the 
fingers and an incision made upward to where the large ves- 
sels enter at the base of the heart. This cut is continued 
downward to the lower right border. From the middle of 
this incision one is made down to the apex. The cut should 
be made from within out, so as to avoid wounding the heart. 

By lifting up the apex of the heart the amount and char- 
acter of the contained fluid can be determined. Is usually 
only 5 to lo c.c. 

The presence or absence of adhesions between the heart 
and pericardium should be noted. Sometimes the entire 
cavity may be obliterated. 

Before making any incisions into the heart, its size, shape, 
and position should be noted. The distention or contraction 
of the various cavities should be determined. 

Opening of the Heart. — This may be done either in situ 
or after removal from the body. As a general thing, it is 
best to remove the heart before making any incisions. It is 
then easier to make the openings, but there is more danger of 
bacterial contamination occurring. 

To remove the heart one grasps the apex with the left hand 
and Hfts up the entire organ. By three or four long cuts 
made from below upward, first severing the inferior vena 
cava, then the left pulmonary vein, and finally the remaining 
vessels, the heart is removed. Care should be taken to 
wound neither the auricles nor the underlying esophagus. 

In opening the heart the primary incisions are made with a 
knife and then united by using long straight scissors with blunt 
points or else a cardiotomc. 

The heart is then placed in a position corresponding to its 
normal one within the body; the apex directed toward the 
operator, the anterior surface being upward. The cavities 
are then opened in the order in which they receive the blood. 

The right auricle is opened by making an incision from the 
inferior to the superior vena cava and then continued into 
the auricular appendage. 

In opening the right ventricle the first cut extends through 
the tricuspid valve down to the end of the cavity. The sec- 



212 A MANUAL OF PATHOLOGY 

ond incision is made about the middle of the primary one 
and at almost right angles to it. This cut should be high 
enough up to avoid cutting through the insertion of the ante- 
rior papillary muscle. It is continued through the pulmon- 
ary valve, following along a slightly marked ridge of fat; by 
so doing the orifice is opened between the left anterior and 
the posterior leaflets. 

The lejt auricle is opened by uniting the four pulmonary 
veins and continuing into the auricular appendage. 

The lejt ventricle has the first incision made through the 
mitral valve between the two papillary muscles along the 
left border of the heart to the apex. The second incision is 
made by beginning at the apex at the end of the first and con- 
tinuing upward close by the interventricular septum and par- 
allel to the anterior coronary artery. The upper end of the 
cut should pass about midway between the pulmonary ori- 
fice and the left auricular appendage. An aortic leaflet is 
generally divided in so doing. 

As the auricles are opened the clots should be removed 
and the valves carefully examined. The size of the opening 
should be noted, so as to determine w^hether or not stenosis or 
dilatation exists. The test of valvular competency by fill- 
ing the cavity with water is unreliable. 

The ventricles are freed from blood and their valves ex- 
amined. 

The anterior coronary artery is examined by opening with 
a pair of probe-pointed scissors. The posterior coronary is 
best seen by placing the tip of the left forefinger over the ori- 
fice of the vessel in the aorta, then cutting from without 
toward the finger-tip until the artery is reached. By so do- 
ing the aorta is not injured. 

The heart should be weighed, its walls measured, the con- 
dition of the valves and muscle noted, and the aorta above 
the valves examined for atheroma. 

Lungs. — In removing the lung all adhesions should be 
broken up or cut through. It is then drawn forward and 
downward, the root being grasped from above between the 
fingers of the left hand. The primary bronchus is divided 



POST-MORTEM EXAMINATION 213 

behind the left hand and the lung is lifted upward, the remain- 
ing attachments being divided. 

If there are dense adhesions between the lung and the dia- 
phragm, it is best to remove the latter with the lung by cut- 
ting through the attachments to the ribs. Be careful to avoid 
wounding either esophagus or aorta. 

The two organs can be distinguished from each other by 
remembering that the anterior edge is thin while the posterior 
is rounded and the bronchi are on the inner surface. Also 
that the right lung has usually three lobes, the left two only, 
although variations occur. 

The lungs may be opened by either a long incision extend- 
ing from apex to base or by a horizontal incision taking in the 
entire width of the organ. The bronchi and blood-vessels 
should be opened with small scissors. 

The cut surfaces should be carefully examined, the color, 
amount of blood, presence of fluid, solidity, degree of crepita- 
tion, smoothness, and friability noted. Portions of the more 
solid areas should be placed in water to see if they will float. 

More room for the examination of the abdominal organs 
can be gained by cutting through the diaphragm on cither 
side of the Hver and turning that viscus upward. 

The spleen is removed by drawing it gently toward the 
mid-hne and the vessels cut close to the hilum. If adherent 
to the diaphragm, care should be taken that its capsule is not 
torn. 

Its size, shape, and density should be noted, as well as the 
appearance of the capsule, trabecuke, blood-vessels, lymph- 
follicles and pulp. 

Intestines. — The intestines are removed next. The 
omentum may either be removed when the abdominal cavity 
is inspected or left till later. It is freed from the transverse 
colon by dividing it close to the gut with a knife. 

The most convenient way to dispose of the intestines is by 
freeing the sigmoid flexure from the mesocolon and divid- 
ing just above the rectum. The transverse colon is freed by 
dividing the two folds of the lesser omentum, the ascending 
by dividing the mesocolon. 



214 A MANUAL OF PATHOLOGY 

To remove the small intestine it should be grasped with the 
left hand and sufficient force exerted to keep the mesentery in a 
state of tension. The blade of the knife is held parallel to the 
intestine and the mesentery is cut at its attachment by means 
of to-and-fro motions. As the intestines are set free they 
should be received into a pan. When the duodenum is 
reached it is ligated and cut on the distal side. The mesen- 
tery is then removed. The gut is then opened, the large 
intestine along one of its longitudinal muscular bands, the 
small along its mesenteric attachment, as o])]30site to that side 
the most important lesions involving the lymph-nodes and 
Peyer's patches are found. 

In order to determine whether or not there is any obstruc- 
tion of the hepatic or common bile-ducts the duodenum 
should be opened in situ. The incision should be along the 
anterior wall and extend from the pylorus to where the duo- 
denum passes beneath the mesentery. The opening of the 
bile-duct is usually marked by a small papilla. Pressure is 
first made on the common duct, and the opening watched to 
see if any obstruction prevents the escape of bile. Pressure 
should then be made upon the gall-bladder to see if its con- 
tents can escape. 

The kidneys may be removed along with the adrenals by 
making an incision to the inner side and then above the adre- 
nal, then cutting along the outer convex border of the kidney 
through the peritoneum and the perirenal fat. The kidney 
is shelled out by using the left hand and the vessels are cut 
from above downward and as near to the aorta as possible. 
When they are divided the organ is raised and the tissues 
loosened with the fingers until the ureter is disclosed, when it 
is severed. 

When the entire urinary apparatus is diseased all the organs 
may be removed together by first dissecting the ureters till 
the bladder is reached, then turning the kidneys downward, 
after which the pelvic organs can be taken out. 

Sometimes the kidneys may be removed without the adre- 
nals, in which case the latter are either opened in situ or 



POST-MORTEM EXAMINATION 21 ^ 

removed separately. The right adrenal is attached to the 
under surface of the liver and must be dissected free. 

The left kidney is generally removed first. 

In examining the kidney it is held between the thumb and 
fingers with the convex surface upward. A deep longitu- 
dinal incision is then made down to the hilum. The cap- 
sule can then be stripped by getting hold of it with the thumb- 
nail. 

The size, color, condition of the surface, and density should 
be noted. Portions of the kidney substance may be removed 
with the capsule. The presence of cysts or of infarcts should 
be determined. On section the relative proportion between 
cortex and medulla, the color of the cut surface, the presence 
of abnormal substances, amount of connective tissue, the 
normal markings of the kidney, the blood-vessels, glomeruli, 
the tubules of the cortex and of the medulla should be care- 
fully noted. The pelvic mucous membrane should also be 
examined. 

The liver is removed by raising up the right lobe and free- 
ing it from all attachments, then the left lobe. If adherent to 
the diaphragm, remove it with the liver. The portal vein 
and the common bile-duct should be examined. 

The tissue is exposed by one or more long cuts on the ante- 
rior surface across both lobes. Should note the amount of 
congestion, the degree of fatty changes, the amount of con- 
nective tissue present, and the degree of bile staining. 

In removing the stomach a portion of the duodenum is 
cut through and lifted up and the stomach, together with the 
pancreas, freed by incisions from below upward. The stom- 
ach is dissected free from the pancreas and opened along its 
greater curvature. If any marked lesions are noticed from 
the outside, the incision should be so made as not to damage 
them. 

The pancreas is examined by making numerous transverse 
incisions. Should be on the lookout for fat necrosis. The 
duct may be slit open along its course. 

In removing the organs of the neck it is best, if allowed, 
to continue the skin incision up to the symphysis of the jaw. 



2l6 A MANUAL OF PATHOLOGY 

The skin is dissected free as far as the hyoid bone and up- 
ward to the chin. The tissues are loosened by passing the 
knife around inside the clavicles. The head should be 
allowed to drop back and a long thin knife is inserted at the 
symphysis beneath the tip of the tongue. By means of a 
sawing motion the muscles are divided first on one side and 
then on the other as far as the vertebral column. The 
esophagus and the trachea are lifted up and the dissection 
continued till the posterior wall of the pharynx is divided. 
The tongue is drawn downward and an incision made on 
either side, well out, so as to divide the lateral pillars of 
the fauces without wounding the tonsils. The soft palate 
is separated and the structures removed. 

The esophagus is opened by being cut along its median line 
posteriorly from the pharynx down. It is then pulled to one 
side, when the larynx and trachea are divided along the pos- 
terior wall. 

The lobes of the thyroid gland should be cut in their long 
diameters. 

The pelvic organs are removed by dividing the perito- 
neum along the brim of the pelvis and dissecting it with the 
fingers till the posterior surface of the rectum is freed. The 
cut end of the rectum is drawn upward and toward the pubes 
while the attachments posteriorly are dissected away. The 
pelvic organs are now attached only at the external openings. 
These are divided anteriorly close to the pubes and poste- 
riorly along the outlet of the pelvis. 

The rectum is opened along its posterior wall and cleaned. 

In opening the bladder a slight incision is made in the 
anterior wall of the fundus and with a pair of scissors the cut 
is continued along the anterior wall through the urethra. 

The uterus is opened by making an incision along the 
anterior wall from the fundus to the cervix. Two secon- 
dary incisions extend from the upper end of the first cut to the 
openings of the Fallopian tubes. The vagina is opened by 
carrying the incision downward. It should be done from 
this direction so that the operator may be sure that any 
foreign substance found in the uterus was not conveyed there 



POST-MORTEM EXAMINATION 21 7 

on the point of his scissors,^ an important consideration in 
medico-legal cases. The ovaries are opened along their 
greatest diameter. 

The testicles can be drawn up through the internal ring 
and examined without any injury to the scrotum. The 
greater portion of the penis can be removed by incising the 
skin as far as the middle of the dorsum and dividing just 
behind the corona. Is then dissected free and withdrawn 
underneath the arch of the pubes. 

The structures now left for examination are the inferior 
vena cava, the thoracic and abdominal aorta, the iliacs, and 
the thoracic duct. They should be slit open. 

Removal of the Brain. — To displace the scalp an inci- 
sion is carried over the vertex from the tip of one mastoid 
process to the tip of the other. This should be made from 
within outward, as by so doing the hair will be divided but 
not cut. The periosteum should be cut through and the two 
flaps dissected free. The anterior one extending nearly to 
the orbits, the posterior is carried backward to the occipital 
protuberance. 

The temporal muscle should be left, but is divided at the 
point where the cut of the saw is to be made. 

The hne of opening the skull extends from a point just 
behind and above the ear, forward over the frontal eminences 
to a corresponding point on the opposite side. By carrying 
this line posteriorly over the occipital protuberance the path of 
the incision is marked out. The incision is started over the 
forehead and carried backward over the line mapped out. 
By bracing the saw with the thumb of the left hand and draw- 
ing backward a correct start can be made. Continue the 
ncision, first on one side and then on the other, till the mas- 
toid processes have been reached. Care should be taken not 
to injure the dura. Is often best not to cut through the 
inner plate of the skull but to break it with a chisel. A 
]30sterior incision is continued backward a little above the 
occipital protuberance. 

It should be noted that there are four points where the 
skull is particularly thick and two where it is very thin. The 



2l8 A MANUAL OF PATHOLOGY 

thick points are over the mastoid processes and in the me- 
dian line anteriorly and posteriorly. The thin points are over 
the temporal fossae, where the skull is so thin that a few blows 
with a chisel will complete the separation. 

By inserting the end of a chisel in the mid-line anteriorly 
and then twisting it the calvarium will be loosened sufficiently 
to allow the inserting of a hook. By pulling, the skull-cap 
will be freed unless there are dense adhesions between it and 
the dura. It is sometimes necessary to remove the calva- 
rium together with the dura. 

To remove the dura insert a small knife and cut from with- 
in outward along the line of the saw incision. Reflect the 
two flaps along the mid-line and examine the surface of the 
brain. The convolutions should be round and not flat. The 
dura is freed from its attachment to the crista galli and dis- 
sected backward. It is separated from the pacchionian 
bodies, to which it is adherent, by means of slight cuts. The 
membrane should be examined carefully and the longitudinal 
sinus opened. The dura should not be cut through poste- 
riorly but should hang down. 

The pia is now exposed and the external appearances of 
the brain should be noted; the degree of congestion, the pres- 
ence of edema, of tubercles, purulent collections and local 
or general thickening. 

The brain is removed by gently elevating the frontal lobes 
until the optic nerves are seen. Care should be taken not 
to cut the olfactory nerves. The optic nerves are cut as far 
forward as possible, then the carotids are severed. 

The tentorium is cut by a sawing motion close to its attach- 
ment to the petrous portion of the temporal bone. The 
various cranial nerves are then divided. 

The spinal cord is severed by inserting the scalpel as far 
as possible into the spinal canal and cutting through with an 
obhque incision from one side to the other. At the same 
time the vertebral arteries are cut. 

The brain during this should be supported by the left hand. 

The base of the skull should be examined, and if a frac- 
ture is suspected the dura is stripped off. 



POST-MORTEM EXAMINATION SIQ 

To examine the bram place it on its vertex with cerebel- 
lum toward one. The pia and the cranial nerves should be 
examined. Then carefully note the arteries for changes in 
size, malformations, presence of atheroma, aneurysms, or of 
tubercles. Separate the Sylvian fissure and examine the 
vessels there as tubercles, emboli, ancur)'sms, and hemor- 
rhage may be discovered although absent elsewhere. 

To section the brain the following method is generally 
employed: The brain is placed on its base and the hemi- 
spheres separated till the corpus callosum is exposed. The 
first incision is made into the lateral ventricle about 3 mm. 
from the median line of the corpus callosum and extending 
into the anterior and posterior cornua. Posteriorly the con- 
volutions over the cornua are cut throus^h. A series of incis- 

o 

ions are made through the hemisphere just external to the 
basal ganglia with their edges coinciding but going at an 
angle of about 45 degrees. This gives a number of wedge- 
shaped portions, held together by the pia, which should not 
have been removed. 

The brain is turned half around and the process repeated 
on the other side. Care must be taken not to injure the 
ganglia when opening the ventricle. 

The corpus callosum is gently lifted and divided by pass- 
ing a knife through the foramen of Monro and cutting from 
below upward. The cut portions are reflected, exposing the 
velum interpositum and the choroid plexus. The third ven- 
tricle is disclosed by drawing back the velum interpositum. 

The vermiform process is cut through, opening the fourth 
ventricle; the aqueduct is cut and all the ventricles are exposed. 

The corpora quadrigemina are found by dividing the right 
posterior pillar of the fornix and reflecting it to the left. 

The basal ganglia are exposed by making a series of trans- 
verse cuts, the brain being supported from below by the left 
hand. 

The pons and medulla are cut transversely into thinsections. 

The cerebellum is divided along the median line into two 
halves, each of which is subdivided by a series of incisions 
at right angles to the primary cut. 



220 A MANUAL OF PATHOLOGY 

This method is the one that is employed when the organ 
has to be examined when fresh. In this way, however, the 
relations of the different parts may be much disturbed. The 
best way is to harden the entire brain, either in Mliller's fluid 
or in formaldehyde. When hardened a series of incisions is 
made transversely through the entire thickness of the organ 
and extending from one end to the other. 

In cutting into the fresh brain the blade of the knife should 
always be wet so as to prevent its adhering. As long as the 
pia has not been divided the brain can be restored to its nor- 
mal form by replacing the wedge-shaped pieces. 

The middle ear and the orbits are exposed by breaking 
through the roof. In removing the eye the anterior half 
should be left and the space filled with cotton. The incision 
is made just posterior to the conjunctival margin and the 
optic nerve should be removed with it. 

Removal of the Spinal Cord. — This may be done either 
before or after the abdominal and thoracic cavities have been 
examined. 

The body is placed prone with the head over the edge of the 
table and a block under the abdomen so as to lessen the lum- 
bar curve. An incision is made from the occiput to the sa- 
crum along the spinous processes. The skin and muscles are 
dissected away on either side, exposing the laminae at the bot- 
tom of the groove, which should be thoroughly clean. By 
means of a double- or single-bladcd saw the laminae should 
be divided so as to enter the spinal canal at its outside Hmits. 
The laminae of the cervical vertebrae are more easily bitten 
through with strong bone forceps. 

Divide the spinous processes on either side, cut the Hga- 
ments in the lower lumbar region, and Hft them up to the 
neck. 

The dura over the cauda equina is picked up with forceps 
and the nerves are cut from below upward ; if done carefully, 
the posterior root ganglia can be removed with the cord. At 
no time should the cord be pulled or bent. 

The dura should be opened by a longitudinal incision, 
made with probe-pointed scissors, either along its anterior 



POST-MORTEM EXAMINATION 221 

or posterior surface. Transverse sections of the cord, about 
2 cm. in thickness, should be made; the incisions coming in 
between each two pair of nerves and leaving the segments 
attached to the pia. 

A diagnosis is frequently made with difficulty from the 
fresh macroscopic appearance of the cord. 



CHAPTER XVI 
LABORATORY TECHNIQUE 

EXAMINATION OF FRESH MATERIAL 

The examination of fresh material may be made by teasing 
the tissue in water or preferably 0.6 per cent, sahne solution. 
This, however, may not be satisfactory unless the tissue has 
been allowed to remain in some fluid long enough for the cells 
to become separated from the basement membrane. This 
is known as maceration; the following fluids are used for 
this purpose. 

1. Thirty- three per cent, alcohol (Ranvier), in which soak 
the specimen twenty-four hours. 

2. Very weak chromic acid solutions, i : 10,000, or its salts. 
Miiller's fluid is especially useful for nervous tissue. Leave 
in the acid twenty-four hours; in the latter three to five days. 

3. One per cent, osmic acid for twelve to twenty-four 
hours. Is useful if there is any fat present. 

4. Potassium hydrate, 33 per cent., for from fifteen to 
twenty minutes. The specimen should be examined in the 
same fluid, as water distorts the cells. To preserve the tis- 
sue wash in 50 per cent, acetic acid, then in water, and after 
staining in alum carmin can be mounted in glycerin. Is 
good for the examination of tissues or tumors that contain 
smooth, involuntary muscle-fibers. 

5. Arnold's method: The small piecesof tissue are placed 
for five to ten minutes in i per cent, acetic acid, then for 
twenty-four to forty-eight hours in the weak chromic acid 
solution. They may finally be stained with picrocarmin. 

Various reagents may be used in the examination of fresh 
specimens to render them transparent, to bring out certain 
details, or to cause various substances to disappear. 



LABORATORY TECHNIQUE 223 

1. Glycerin clears the tissues and has the advantage of not 
changing chemically nor getting thin. Permanent mounts 
may be made by sealing the edges of the cover-glass with 
paraffin. 

2. Potassium acetate in a saturated watery (50 per cent.) 
solution has a clearing action similar to but less marked than 
glycerin. 

3. Acetic acid: Has the advantage that it causes the 
nucleus to shrink and the connective tissue to swell and 
become transparent. It does not affect fat, but dissolves the 
proteid granules, so differentiates the two processes. Elas- 
tic fibers and micro-organisms are unaffected, so stand out 
prominently against the changed connective tissue. The 
acid may also be used to dissolve calcium salts. Solutions 
of I to 2 per cent, are generally employed, but the pure glacial 
acetic acid may be used. 

A solution of acetic acid with fuchsin may be employed 
and in that way stain the nuclei. 

4. Weak watery solutions of iodin. The following solu- 
tion (Lugol's) is mixed with 3 to 5 parts of water: 

Iodin 1 .0 

Potassium iodic! i.o 

Distilled water loo.o 

This brings the nucleus and the cell contour more plainly 
to view and also stains glycogen and amyloid particles 
brown. 

5. Potassium and sodium hydrate solutions of from i to 3 
per cent, have the power to dissolve most tissues, but do not 
affect elastic tissue, fat, bone, pigment, bacteria, or amyloid. 
Thirty-three per cent, solutions dissolve the cement substance 
and isolate the cells. This reaction takes place in a few min- 
utes. 

6. Osmic acid in i per cent, watery solution will stain fat, 
black or brown. 

7. Hydrochloric acid in from 3 to 5 per cent, is used for the 
recognition of Hme salts, cither in boneorin the tissues which 
it dissolves with the production of bubbles of CO 3. 



224 A MANUAL OF PATHOLOGY 

8. Fresh preparations may be stained by allowing a few 
drops of watery stains to pass under the cover-glass and then 
washing out the excess. Methyl-green, Loeffler's methylene- 
blue or acetic acid fuchsin may be used. Hematoxylin is 
unsuitable. 

FIXATION AND HARDENING 

If a more exact examination is desired, the tissues must 
be hardened and fixed. The material should be placed in 
the fluid used as soon as possible after it has been obtained. 
The point desired is that the conditions as they exist in the 
tissues during life shall be retained. 

The different solutions vary greatly in their power of pene- 
tration and also in their effects upon different tissues. The 
action is facihtated by cutting the specimen in small pieces. 
After fixing and hardening it is generally necessary to 
thoroughly wash so as to remove all traces of the agent em- 
ployed. 

The points to be observed are : 

The specimens should not be more than 2 cm. in thickness. 

The volume of reagent used should be from ten to fifteen 
times larger than the bulk of the specimen. 

Place a layer of absorbent cotton or filter-paper in the bot- 
tom of the jar so that the tissue may be acted upon by the 
fluid from all sides. 

After sufficient hardening remove the specimen and wash 
it in running water for twelve to twenty-four hours. It is 
then passed through alcohols of various strengths — 70, 80, 
and 90 per cent., about twenty-four hours in each. 

Alcohol. — It is used for rapid work and particularly if 
bacteria are suspected. It is not good for nervous tissue. 
Specimens should, as a rule, be put in weaker alcohol before 
being placed in absolute. This method is not used as 
much as formerly on account of the shrinking and distor- 
tion of the tissues and the destruction of the red blood- 
corpuscles. 

The so-called absolute alcohol is usually little more than 
95 per cent. To extract the water, copper sulphate should 



LABORATORY TECHNIQUE 22$ 

be heated till the blue color disappears and then added to the 
alcohol. The alcohol should be filtered before using and the 
copper sulphate reheated when it begins to turn blue. 

Formalin. — This reagent is being used very greatly in 
place of alcohol. It has numerous advantages. The hard- 
ening takes place rapidly, the erythrocytes and other pig- 
ments retain their natural colors. 

As formahn is bought it consists of a 40 per cent, solution 
of formaldehyde in water. The strength commonly used is 
a I : 10 or a 4 per cent, solution. 

The tissues are left from four to six hours in the 4 per cent, 
solution, then thoroughly w^ashed in water, and finally passed 
through alcoholic solutions of varying strengths. 

Formalin is also used in combination with other mixtures, 
particularly as Orth's solution. This is made by adding ten 
parts of formalin to one hundred parts of Mliller's fluid. 
This should be made fresh, as in the course of five or six days 
there is a crystalline precipitate formed. This fixes nuclear 
figures very well and hardens small pieces of tissue in from 
three to six hours. It is particularly important that they 
should be very carefully washed in running water. Is good 
for nervous tissues. 

3. Mueller's fluid is made up of: 

Potassium bichromate 2.5 

Sodium sulphate i .0 

Distilled water 100. o 

This should be used in large quantities and should be 
changed every second day for about five times and then be 
replaced whenever the solution becomes cloudy. To pre- 
vent the growth of mold one gram of bichlorid of mercury 
should be added to two liters of the fluid. 

For thorough hardening of small objects from ten to twelve 
weeks is required; for a large object like the brain, a year. 
The process can be hastened by placing the preparation in 
an incubator and frequently changing the fluid. 

After complete hardening the preparation is carefully 
washed in water, and then run through increasing strengths 
15 



2 26 A MANUAL OF PATHOLOGY 

of alcohol. The sections stain well with hematoxylin and 
eosin. The red corpuscles are well preserved. 

4. Erlicki^s fluid consists of: 

Potassium bichromate 2.5 

Sulphate of copper 0.5 

Distilled water loo.o 

This fluid has the advantage that preparations will harden 
in from eight to ten days; and if in the incubator, in from 
four to five days. Its disadvantages over Mueller's fluid are 
that it does not prevent shrinking as well and that there is 
frequently a precipitate in the tissues. 

5. Bichlorid of mercury is of particular value in the 
flxation of cells and mitotic figures, but it has very little pene- 
trating power. All the solutions that contain bichlorid have 
the drawback that there is a precipitation of mercury in the 
tissues that may be mistaken for pigment unless removed. 
These compounds may be dissolved by the addition of several 
drops of iodin to the 80 per cent, alcohol into which the spec- 
imens arc put after having been washed. The iodin may be 
added to the alcohol in which the cut specimens arc placed 
before being stained. 

6. Zenker's fluid. 

Bichlorid of mercury 5.0 

Potassium bichromate 2.5 

Sodium sulphate i .0 

Distilled water loo.o 

Glacial acetic acid 5.0 

The mercury and bichromate are dissolved in warm water 
and the sodium then added. It is best not to add the glacial 
acetic acid till the solution is ready to be used, as the acid 
rapidly evaporates. 

After being in the fluid for twenty-four hours or less accord- 
ing to the size of the specimen, it is thoroughly washed in 
running water twelve to twenty-four hours and then hardened 
in alcohol. The tissue should be passed through 80 per cent. 
alcohol containing iodin so as to remove the precipitate of 
mercury that forms. 



LABORATORY TECHNIQUE 227 

Tissues prepared in this way stain according to all methods. 
The chromatin figures are well preserved as well as the ery- 
throcytes. 

7. Osmic acid. — Its penetrating power is very slight, so 
very thin pieces of tissue, not more than 5 mm. in thickness, 
can be used. 

A I per cent, watery solution is usually employed. It 
should be kept in the dark, and when the specimen is fixed, 
well washed. The paraffin method of imbedding should be 
employed, using chloroform or clove oil, as the celloidin will 
dissolve out the fat. In clearing do not use xylol, as it also 
dissolves fat. 

8. Flemming's Solution. — 

1 per cent, aqueous chromic acid solution. .15.0 

2 per cent, aqueous osmic acid solution. . . 4.0 
Glacial acetic acid i.o 

The small bits of tissue are left in the fluid one to three days, 
well washed for several hours, then hardened in increasing 
strengths of alcohol. Is used for karyokinetic figures and 
for fat. Stains best with watery safranin. 

Hermann's fluid is a modification of the above. A 
I per cent, platinum chlorid solution is used instead of the 
chromic acid. The nuclear figures are especially well pre- 
served. The method of employment is the same as with 
Flcmming's. 

DECALCIFICATION 

General Rules. 

The tissue must be well hardened before being put in the 
decalcifying fluid, otherwise it will be much altered. The 
formalin method is well adapted and small pieces should be 
used. 

An excess of fluid should be used and it should be fre- 
quently changed. After complete decalcification the tis- 
sue should be carefuHy washed for two or more days. It 
must then be rehardened before it is ready to cut. The tis- 
sue is decalcified if it allows a needle to penetrate without 
meeting distinct resistance. 



228 A MANUAL OF PATHOLOGY 

The following are the fluids commonly used : 

1. Chromic acid and its salts. JSIueller's fluid for small 
pieces of bones or embryonal bones. Is a very slow process. 
Can be hurried by placing in an incubator. 

2. Saturated watery solution of picric acid. Requires 
about three weeks for embryonal bones. Larger and older 
pieces take several months. Can be hastened by adding 
3 to 5 per cent, of nitric acid. To remove the picric acid, 
wash the tissue, then place in 95 per cent, alcohol to which 
several drops of a saturated watery solution of lithium car- 
bonate have been added. The fluid becomes colored and 
more carbonate should be added till it remains completely 
clear. 

3. Hydrochloric acid. When used in i to 10 per cent, 
solution it works quite rapidly, but injures the tissues. 
Is best used as : 

Ehncr's fluid: 

Hydrochloric acid 2.5 

Alcohol 500-0 

Distilled water loo.o 

Sodium chlorid 2.5 

This method can be hastened by increasing both the hydro- 
chloric acid and sodium chlorid to 5 per cent. 

4. Nitric acid, in from 3 to 10 per cent, in water or for- 
malin, is well adapted for bone tissue from adults. The 
alteration to the tissue is less than when corresponding solu- 
tions of hydrochloric acid are used. 

Haug recommends the following on account of its more 
rapid and better action : 

Nitric acid, c. p 30.0 to 90.0 

Absolute alcohol 700.0 

Distilled water 300.0 

Sodium chlorid 2.5 

5. Phloroglucin. This protects the tissues from the 
action of the acid, so that very strong solutions may be used. 
It acts very rapidly; small pieces are decalcified in half an 
hour, larger ones in several hours. 



LABORATORY TECHNIQUE 229 

A stock solution is made consisting of : 

Nitric acid, c. p 10. o c. c. 

Phloroglucin i.o gram. 

This is carefully dissolved by warming; is best done under 
a hood. To this is added loo c.c. of a lo per cent, aqueous 
solution of nitric acid. 

A more slowly working mixture is: 

Phloroglucin i.o 

Nitric acid 5.0 

Alcohol 70.0 

Distilled water 30.0 

Thoma^s method is to : 

1. Harden in Mueller's fluid or alcohol. 

2. Decalcify in: 

Alcohol 5.0 

Nitric acid 1.0 

changing the solution very frequently. 

3. Wash in alcohol. 

4. Wash thoroughly in alcohol to which has been 

added an excess of calcium carbonate. 

The decalcification requires from two to three weeks for 
large pieces. To remove the acid the tissue has to be in 
the carbonated alcohol from eight to fourteen days; should 
remain till there is no acid reaction with htmus paper. 

6. Trichloracetic acid, used in 5 per cent aque- 
ous solution and frequently changed, decalcifies in from 
five to seven days; generally with good results. 

INJECTION 

For the purpose of making them more easily studied the 
blood-vessels and other hollow structures may be filled with 
some injecting material that contains a stain. This pro- 
cedure is not frequently used for pathologic purposes. 

IMBEDDING METHODS 

The purpose of imbedding is to give to a tissue a sufficient 
firmness to permit the cutting of thin sections. Two methods 



230 A MANUAL OF PATHOLOGY 

are commonly employed, one with celloidin, the other with 
paraffin. 

Celloidin has the advantage of not requiring heat, and can 
be used for larger pieces of tissue. On the evaporation of the 
alcohol and ether a comparatively solid mass remains. 

Paraffin can be used for small pieces of tissues only. It 
also renders the specimen brittle so that it is frequently 
difficult to cut good sections. Although fluid when kept at 
the necessary heat, the paraffin becomes hard on cooling. 

Celloidin Method. — In this process two solutions of 
celloidin of different thickness are employed — one of the 
consistency of syrup, the other of that of molasses. These 
solutions are made by adding to a mixture of equal parts of 
absolute alcohol and ether enough celloidin to give the 
desired consistency. The specimens must be thoroughly 
dehydrated in absolute alcohol and then placed in equal 
parts of absolute alcohol and ether for twenty-four to forty- 
eight hours. This latter step is not essential, but is advisable. 
From the alcohol the specimens are left in the thin celloidin 
at least twenty-four hours and in thick celloidin for a hke 
period. If there is no hurry, the longer the time in each 
celloidin solution, the better will be the result. They are 
then placed on blocks, covered with thick celloidin, and 
allowed to harden. In the course of a few minutes, when 
the block can be turned upside down without the specimen 
sliding off, they should be placed in 80 per cent, alcohol. 
After remaining there for several hours they are ready to cut. 

The blocks best adapted for use are those made out of 
vulcanite or hard paraffin. The latter are particularly con- 
venient. A square of hard paraffin is cut up into blocks of 
various sizes and the tops roughened with a knife so as to 
give a better surface for the celloidin to ahdere to. Cork 
and wood are not well adapted, as after being in the alcohol 
for any length of time the tannic acid is extracted; it pene- 
trates the specimen and interferes with its staining proper- 
ties. 

In cutting celloidin sections the knife is clamped at a very 
marked slant, so that as much of it as is possible will be used. 



LABORATORY TECHNIQUE 23 1 

The blade and the specimen should be kept constantly wet 
with 80 per cent, alcohol. As the sections are cut they are 
hfted off the knife with a camel's-hair brush and placed in a 
dish containing water. This causes them to flatten out. 

After the staining has been completed the sections are 
passed through graded alcohols to remove the water and are 
then placed in some fluid that will clear them. Clove oil 
should not be used, as it dissolves the cefloidin. Bergamot, 
cedar oil, creosote, and xylol, alone or in combination with 
one part of carbolic to three parts of xylol, do not affect the 
celloidin. 

Summary : 

1. Dehydration in absolute alcohol. 

2. Absolute alcohol and ether, aa . i to 3 days. 

3. Thin celloidin i to 5 days. 

4. Thick celloidin i to 5 days. 

5. Mount on block. 

6. 80 per cent, alcohol 12 to 24 hours. 

7. Cut on microtome. 

8. Stain, dehydrate, and clear. 

9. Mount in balsam. 

Paraffin Method. — The preparation must be thoroughly 
dehydrated in absolute alcohol or anilin oil. It is then 
placed in some fluid that is a solvent of paraffin — xylol 
or chloroform are commonly used — for four to five hours. 
The fluid should be changed several times. Then it is put 
in a mixture of chloroform or xylol and paraffin for two to 
three hours. The infiltration is hastened by heating the 
mixture at about 50° C. It is then placed in paraffin that 
melts at about 50° C. for three to five hours, the paraffin 
having been changed once or twice. The melting-point can 
be varied by making combinations of paraffin that melt at 
different degrees. The two generally used are one of 56° C. 
and another of 45° C. In warmer weather a paraffin with 
a higher melting-point is used. 

The specimen is taken and placed in a little paper box 
in which a small amount of parafhn has been poured. When 
the tissue has been properly arranged more paraffin is added. 



232 A MANUAL OF PATHOLOGY 

The box is then placed in a dish of cold water so that it 
will be rapidly cooled. This prevents crystallization and 
brittleness. Instead of using the paper boxes two right 
angles of metal are put on a glass plate so as to form an en- 
closure. Paraffin is poured in to form a thin film, then the 
tissue, and finally more paraffin. 

After cooling, the specimen is fastened on a block of 
vulcanite or hard paraffin by heating its surface, and is then 
cut on the microtome. The blade is held at a right angle if 
the specimen is small, on a slant if large, and the cutting is 
done dry, no alcohol being used. 

Summary of the paraffin imbedding: 

1. Dehydration in absolute alcohol. 

2. Xylol or chloroform four to five hours, changing the 

fluid a couple of times. 

3. Xylol or chloroform and paraffin, two to three hours. 

4. Melted paraffin in hot chamber at 50° C for 

three to five hours. Change once. 

5. Block and quickly cool. 

6. Cut. 

The paraffin sections are so brittle that they cannot be 
treated in the same way as the celloidin ones. The best 
method is to take the section and place it in a dish con- 
taining water at about 45° C. This causes the specimen to 
flatten. A perfectly clean slide is then smeared with a 
very fine film of glycerin-albumin and is slipped under the 
floating section. The excess of water is drained off or care- 
fully touched with blotting-paper and the slide is then placed 
in the incubator at 37° C. for three to five hours. 

The paraffin should be removed before staining the 
section. This is hastened by holding the slide over a small 
flame till the paraffin becomes transparent, when it is placed 
in xylol or turpentine for about two minutes. From there 
into absolute alcohol for about five minutes. It is ad- 
visable but not necessary to put the sHdes into weaker alco- 
hol before beginning the stain. When the above steps have 
been gone through the tissues may be stained any way that 
is desired. 



LABORATORY TECHNIQUE 233 

Glycerin- albumin solution for fastening paraffin sections 
to the slide is made as follows : The white of an egg is well 
beaten and to it is added an equal volume of glycerin. These 
are thoroughly mixed and filtered. It is used by smearing a 
very thin layer on the slide, the paraffin section is placed on it 
and then heated up to a temperature of about 60° C. till the 
albumin coagulates. If the sections have been taken from 
water it must be allowed to evaporate before the coagulating 
is done. The evaporation will be hastened by placing the 
slides in the incubator. 

CUTTING SECTIONS 

Freezing Microtome. — This method is valuable for 
rapid diagnostic work, but sections cannot often be cut 
sufficiently thin to allow a careful examination of the details. 

The piece of tissue used should not be more than 4 mm. 
high and it must be free from all traces of alcohol. The 
alcohol is removed by placing the specimen in a large 
amount of water that is of a temperature of about 30° C. 

The specimen is placed on the metal stand and a spray 
of ether or of carbonic acid gas is directed against the under 
side. The tissue is held in place by lightly pressing upon it 
with some flat piece of wood, as the handle of a small scalpel. 
Care must be taken not to freeze the tissue too hard or it 
will be so brittle as to break or show irregular streaks. The 
cut sections should be placed in 80 per cent, alcohol, as 
they will unroll better than if put directly into water. 

The freezing method is particularly well adapted for 
tissues that have been hardened in Mueller's fluid, as there 
is no change in the finer characteristics. Formalin is very 
useful, as it permits very good sections to be made and is 
employed especially in the rapid diagnosis of tumors. 

A rapid method is as follows: 

1. Take a small portion of the tissue that has been re- 
moved at the operation and place immediately in a 10 per 
cent, solution of formalin for about two minutes. 

2. Freeze, put the sections into water to flatten. 

3. Stain in hthium carmin two to three minutes. 



234 A MANUAL OF PATHOLOGY 

4. Blot stain and mount in glycerin. 

Serial Sections. — Paraffin. — The block containing the 
specimen is turned till the anterior and posterior edges are 
parallel; as much of the paraffin being removed as is possible. 
The knife is placed at right angles and with rapid strokes of 
the knife the sections are cut. The edges of the sections chng 
to each other and long ribbons may be cut. These ribbons 
should be carefully placed on sheets of toilet paper, carefully 
numbered and marked, so that the beginning of each series 
can be determined. The ribbons are divided into lengths 
convenient for placing on the slide. They are then floated 
on water and picked up on the slide covered with the glycerin- 
albumin. 

STAINING 

The principle of staining depends upon the different 
affinity of certain portions of the tissue for special dyes, so 
that they become more e\'ident for purposes of study. There 
are certain stains which show a distinct affinity " for the 
nuclei, while others select the cell protoplasm and the inter- 
cellular substance. By employing two stains a double 
coloring is obtained. In some conditions a single color may 
affect different portions of the tissue differently. 

According to their reaction, stains are divided into the 
basic, which are commonly nuclear or chromatin stains, and 
the acid, those that affect the cell protoplasm or the inter- 
cellular tissue. Neutral stains are generally artificial com- 
binations of some of the above two. 

After being stained it is generally well to differentiate. 
Although a stain may be a nuclear one, yet there is usually 
some effect upon the other substances, the same holding 
true in regard to the acid stains. To remove this color, 
certain fluids are used, as water, weak solutions of acid in 
water or alcohol, alcohol, anilin oil, and tannic acid. 

It is also necessary that the sections shall be rendered 
transparent,- and this is brought about by placing them in 
xylol, carbol-xylol, oil of clove, creosote, or bergamot. 

Certain general rules should be observed : 



LABORATORY TECHNIQUE 235 

1. All staining fluids should be filtered before use to 
avoid precipitates in the tissue. Good stains should be used, 
the best being those of Dr. Griibler, of Leipzig. 

2. The sections should be spread out in the stain and 
should not lie upon each other, as the fluid is then likely to 
stain unevenly. Large amounts of stain in large dishes should 
be employed. Is is also an advantage to carefully move 
the sections to and fro. 

3. The time required for staining varies, as a rule being 
less in old, well-ripened stains than in others freshly prepared. 
This depends also upon the proper hardening and fixation of 
the tissue, and also upon its age. Fresh tissues will stain 
more deeply and more quickly than old ones. 

4. The staining of refractory tissues may be assisted by : 

(a) Concentration of the stain. 

{b) Staining for a longer time, up to twenty-four 
hours. 

(c) Heating up to 37° C. 

(d) Adding mordants, as acids and alkalies, anilin oil, 

etc. 

5. The sections should be carefully washed in water to 
remove all traces of the decolorizing agents used. 

6. Sections should be thoroughly dehydrated before 
being mounted, otherwise those areas containing water will 
not be transparent and will contain what appear to be oval 
pigment particles. 

Method of staining and mounting sections: 

1. Stain. 

2. Wash, usually in distilled water. 

3. 80 per cent, alcohol two to three minutes. 

4. 95 per cent, alcohol three to five minutes. 

5. Absolute alcohol two to three minutes. 

6. Clearing fluid till the specimen sinks below the 

surface, two to three minutes. 

7. Place section on slide, blot off the excess of clear- 

ing fluid, and mount in balsam, using a cover- 
glass. 



236 . A MANUAL OF PATHOLOGY 



NUCLEAR STAINS 

Aqueous alum hematoxylin solution. 

Hematoxylin crystals i gm. 

Sat. aq. sol. ammonia alum 100 c.c. 

Water 300 c.c. 

Thymol a crystaL 

Dissolve the hematoxylin in a Httle water by the aid of 
heat. After the solutions have been mixed expose to the 
hght and air in an unstoppered bottle for about ten days. 
Then tightly cork. 

Delafield's hematoxylin. 

Hematoxylin crystals 4 gm. 

Alcohol (95 per cent.) 25 c.c. 

Sat. aq. sol. ammonia alum 400 c.c. 

Dissolve the hematoxylin in the alcohol, then add the 
alum solution. Expose the mixture to the air and light four 
to five days. Then filter and add : 

Glycerin 100 c.c. 

Alcohol (q5 per cent.) 100 c.c. 

Expose to light and air for a couple of weeks, then filter and 
keep tightly corked. The solution lasts well and stains the 
more rapidly the older it gets. 

Ehrlich's acid hematoxylin. 

Hematoxylin crystals 2 gm. 

Absolute alcohol _ 60 c.c. 

Glycerin 60 c.c. ] saturated 

Water 60 c.c. }■ with am- 

Glacial acetic acid 3 c.c. J monia alum. 

The solution is ripened in an uncorked bottle till it becomes 
deep red in color; requires a couple of weeks. If kept in 
well-stoppered bottle precipitates do not form and the solu- 
tion retains its staining powers for years. Also does not over- 
stain. 



LABORATORY TECHNIQUE 237 

Mayer's hematein. When hematein is used, ripening 
is unnecessary, but the results from such stains are not as 
satisfactory as when hematoxyhn is used: 

Hematein 0.4 gm. 

(Dissolve in a few drops of glycerin) 

Alum 5 .0 gm. 

Glycerin 30.0 c.c. 

Water 70.0 c.c. 

Hematoxylin Staining. — The nuclei are stained blue. 
The older the solutions, the quicker they act and the deeper 
they stain. If the sections are overstained, the excess of 
color can be removed by placing them in hydrochloric acid 
alcohol till the proper color is obtained. The acid causes 
the blue to change to a brown, but the color is regained when 
the sections are placed in water. The acid should be thorough- 
ly washed out ; this can be hastened by using water to which 
an equal amount of a saturated watery solution of lithium 
carbonate has been added. 

1. Stain three to ten minutes according to age of stain. 

2. Wash thoroughly. 

3. Differentiate with acid alcohol, about thirty seconds 

if sections are overstained. 

4. Wash thoroughly. 

5. A counter-stain, eosin, is usually employed. 

6. Dehydrate, clear, and mount in balsam. 

Alum carmin. 

Carmin i gm. 

5 per cent, alum solution 100 c.c. 

Boil for one-half to one hour and when cool filter. It 
stains the nuclei a violet red. There is no danger of over- 
staining and the color is not very easily removed in water or 
weak acid solutions. This preparation docs not work 
well with objects that are difficult to stain. 
The sections are placed : 

1. In the stain for ten minutes to two hours. 

2. Then washed thoroughly in distilled water. 



238 A MANUAL OF PATHOLOGY 

3. Dehydrated in alcohol, cleared and mounted. 
Lithium carmin. 

Carmin 2.5 to 5.0 gm. 

Sat. sol. lithium carbonate loo.o c.c. 

Heat and filter. The nuclei are stained an intense red. Is 
well adapted for tissues that stain with difficulty. Any 
excess of color can be removed in acid alcohol. Is a good 
counter-stain for tissues that have been injected with blue 
substances. 

Sections are placed : 

1. In the stain for two to three minutes. 

2. Washed in water. 

3. Differentiated for one-half to one minute in acid 

alcohol; hydrochloric acid i, 70 per cent, 
alcohol 100. 

4. Washed thoroughly so as to remove the acid. 

5. Dehydrated in alcohol, cleared, and mounted in 

balsam. 

Picro-lithium carmin. 

Lithium carmin solution i part 

Sat. watery sol. picric acid 2 parts 

Sections arc 

1. Stained three to five minutes. 

2. Washed. 

3. Differentiated two to three minutes acid alcohol. 

4. Washed thoroughly. 

5. Dehydrated in alcohol that has had a Httle picric 

acid added to it. 
7. Cleared an'd mounted. 
Nuclei are stained brownish-red, and the protoplasm 
yellow. 

Borax carmin. 

Carmin 0.5 gm. 

Borax 2.0 gm. 

Distilled water lOO.o c.c. 



LABORATORY TECHNIQUE 239 

Mix and heat till boiling begins ; should be stirred constantly ; 
then add 4.5 parts of dilute acetic acid (0.5 per cent.) and let 
stand twenty-four hours; then filter. 

This gives the same results as the lithium carmin except 
that the color is not so intense. 

Sections placed : 

1. In stain for five to fifteen minutes. 

2. Washed in water. 

3. Differentiated one-half to one minute in acid alcohol 

solution. 

4. Washed in water thoroughly to remove acid. 

5. Dehydrated, cleared, and mounted. 
Bismarck brown. 

Either a 3 to 4 per cent, watery solution obtained by 

boiling and filtering. 
Or a concentrated alcoholic solution made in 40 per 
cent, alcohol, equal to i J to 2 per cent. 
Sections are : 

1. Stained five minutes. 

2. Washed in alcohol or i per cent, hydrochloric acid 

alcohol. 

3. Dehydrated, cleared, and mounted. 

The nuclei are stained a deep brown, the protoplasm a 
fighter color. Bacteria are an intense brown. Cannot over- 
stain. This method is especially adapted for micro-photo- 
graphic work. 

Gentian-violet. Either a i per cent, watery or a 2 per 
cent, alcohofic solution may be used. Are likely to overstain. 

Sections are : 

1. Stained three to five minutes. 

2. Washed in alcohol till they become a pale blue, 

3. Then in absolute alcohol. 

4. Cleared and mounted. 

The nuclear staining is clearer if the sections are put for 
fifteen to thirty seconds in a ^ per cent, solution of acetic 
acid and then into the alcohol. 

Safranin. — Is usually employed after fixing in Flem- 
ming's solution to bring out karyokinetic figures. 



240 A MANUAL OF PATHOLOGY 

Sections : 

1. Stained one-half to twenty-four hours in a i per 

cent, watery solution of safranin. 

2. Quickly washed in water. 

3. Washed in absolute alcohol to which 5 to 10 drops 

of I per cent, hydrochloric acid alcohol have 
been added. 

4. Washed in pure absolute alcohol till the section 

is a clear brown. 

5. Cleared and mounted in alcohol. 

The resting nuclei are pink, those undergoing mitotic 
changes are deep red. 
Another method is: 

Anilin oil 2.0 c.c. 

Water loo.o c.c. 

Safranin in excess. 

Heat to 60° C. and filter. The solution will last about two 
months. This form stains almost immediately. The after- 
steps are as above. 

DIFFUSE AND DOUBLE STAINING 

Double staining is employed for the purpose of obtaining 
a contrast between the nuclei and the plasms and inter- 
stitial substance. The nuclear stain is employed first, as 
the contrast stain is weaker and colors the tissues more 
diffusely. 

Neutral Carmin. 

Carmin powder 5.0 gm. 

Aq. ammon. fort i .0 c.c. 

These rubbed together then add : 

Distilled water 200.0 c.c. 

Boil till the ammonia is driven off. Allow the solution to 
stand uncorked for about a week, then filter. The solution 
works better as it becomes older. 



LABORATORY TECHNIQUE 24I 

To prepare the stain for immediate use add just enough 
ammonia to the carmin to make a paste. This should be 
thinly spread on the sides of the mortar and allowed to dry. 
Pulverize again, let it remain exposed to the air for twenty- 
four hours, then dissolve in cold water; it is then ready for 
use. 

To stain sections: Add the stock solution to distilled 
water until a clear pale red color results. The sections remain 
in this until they become plainly red, up to twelve hours. The 
best results are obtained by staining for a long time in a 
weak solution. Strong solutions stain more rapidly. Wash 
thoroughly in water, dehydrate, clear and mount. 

The counter-stain best used is hematoxyhn, and it 
should be employed first. 

Eosin. — Either the form soluble in water, which is the 
better, or that in alcohol may be used. A few drops of a con- 
centrated solution of either variety is added to a small dish 
of water and the sections stained till they are of a reddish 
color — one to three minutes. 

Then washed in water. 

Dehydrated in alcohol. Should be careful not to leave 
in the alcohol too long, as it gradually dissolves out the stain. 

Cleared and mounted. 

This method is preceded by staining in hematoxylin. In 
such cases the nuclei arc blue. In specimens fixed in forma- 
lin or sublimate solutions the red blood-cells stain a bright red 
or copper color and.the blood-vessels are prominent. Eosino- 
phile cells show up plainly. The other tissues show a diffuse 
reddish tinge. 

Picric acid is generally used in combination with some 
other stain, as in Van Gieson's method. As the picric acid 
decolorizes the sections, they should be overstained in the 
hematoxyhn. If iron hematoxylin is used instead of Dcla- 
ficld's, the decolorization does not occur to the same extent. 

Van Gieson's method for nervous tissue : 

I per cent, aqueous sol. acid fuchsin 15 c.c. 

Sat. aq. sol. picric acid 50 c.c. 

Water 50 c.c. 

16 



242 A MANUAL OF PATHOLOGY 

For connective tissue : 

I per cent. aq. sol. acid fuchsin 5 c.c. 

Sat. aq. sol. picric acid 100 c.c. 

Sections are : 

1. Overstained in Delafield's hematoxylin. 

2. Washed thoroughly in water. 

3. Stained in Van Gieson solution three to five 

minutes. 

4. Washed in water one-half minute. 

5. Dehydrated, cleared, and mounted. 

Nuclei are stained brownish- red; connective tissue, vary- 
ing shades of hght red; axis-cylinders, brownish-red; myelin 
sheaths, yellow; neuroglia and sclerosed fibers, red ; amyloid, 
rose or reddish-brown; hyaline, red; colloid, orange or red. 

CONNECTIVE TISSUE STAINS 

Van Gieson's stain, as already given, may be used. The 
best results are obtained after fixation in chrome salts or sub- 
limate solutions; are not so good after alcohol. 

Mallory^s anilin blue stain gives good results after 
fixation in Zenker's fluid or sublimate solutions. The 
fibrillae and reticulum of connective tissue, amyloid, mucous, 
and other hyaline substances stain blue; the connective tissue 
can be differentiated from the other substances by their 
form. Nuclei, protoplasm, fibroglia fibrils, axis-cylinders, 
neurogha fibers, and fibrin stain red ; erythrocytes and myelin 
sheaths yellow ; elastic fibers pale pink or yellow. 

Sections are : 

1. Stained in a y^- per cent, aqueous solution of acid 

fuchsin five or more minutes. 

2. Transfer to the following solution and stain 

twenty minutes or more: 

Anilin blue soluble in water (Grubler) 0.5 gm. 

Orange G. (Grubler) 2.0 gm. 

I per cent, aqueous solution of phosphomo- 

lybdic acid 100. o c.c. 



LABORATORY TECHNIQUE 243 

3. Wash and dehydrate in several changes of 95 per 

cent, alcohol. 

4. Clear in xylol or in oil of origanun (Cretici). 

5. Balsam. 

ELASTIC FIBER STAIN 

Weigert's stain for elastic fibers. It is best to buy the 
stain already made up, as its preparation is rather difficult. 
The sections are: 

1. Stained in the above solution for twenty minutes 

to an hour. 

2. Washed off in alcohol. 

3. Blotted v^ith filter-paper, xylol added, and blotted 

two or three times till the section is clear. 

4. Mounted in balsam. 

The elastic fibers are dark blue, almost black. 

Unna's orcein stain. 

Orcein i gm. 

Hydrochloric acid i c.c. 

Absolute alcohol 100 c.c. 

Sections are : 

1. Stained six to twenty-four hours. 

2. Washed thoroughly in 70 per cent, alcohol. 

3. Washed in water to get rid of the acid. 

4. Dehydrated, cleared, and mounted. 

The elastic fibers are a deep silky brown color, connective 
tissue a pale brown. This method has the advantage that 
elastic fibers that have degenerated into clacin take the basic 
blue stain. 

BLOOD STAINING 

Before being stained the blood must be fixed to the sHde 
either by heat or by some chemical. 

Heat may be used in all cases except when Wright's 
stain is employed; it must be used with Ehrhch's triple stain 
to get good results. The films should be exposed to a dry 
heat of from 100° C. to 110° C. for ten to fifteen minutes. 



244 A MANUAL OF PATHOLOGY 

Chemicals. — The smears are fixed in absolute alcohol 
or ether or a mixture of equal parts of the two for five to ten 
minutes. Then dried and stained. 

Stains. — Wright's. — Is best to procure this stain ready- 
made. It is employed as follows, as no previous fixing is 
necessary : 

The unfixed film is covered with the solution and stained 
for a minute. Distilled water is added drop by drop till a 
metallic scum appears on the surface of the fluid and is al- 
lowed to remain two to three minutes. Then wash the film, 
which is deep blue or purpHsh color, till it becomes yellowish 
or pink. Dry between blotting-paper and mount in balsam. 

The erythrocytes will be stained orange or pink; the 
nuclei of the leukocytes, blue; neutrophile granules, lilac; 
eosinophil granules, pink; fine basophile granules, deep blue; 
coarse mast cell granules, deep purple. The malarial 
organism stains blue. 

Ehrlich's Triacid. — Best bought ready-made. 

After fixing with heat, stain five to eight minutes, wash in 
running water, dry and mount. 

Erythrocytes stain orange; nuclei of the leukocytes, 
greenish-blue; neutrophile granules, violet or lavender; 
eosinophil granules, copper red; basophile granules are 
unstained. 

Polychrome Methylenc-hlue (Goldhorn's). — Isbought ready- 
made. 

After fixation for fifteen to twenty seconds in methyl- 
alcohol, wash in water and, without drying, stain for one to 
two minutes. Wash thoroughly in running water, dry with 
blotting-paper, and mount. 

This method shows very well granular degenerations of the 
erythrocytes, the nuclei of erythroblasts and leukocytes, 
basophihc granules, and most bacteria. It is a very good 
stain for the malarial organism. If the film is first stained for 
ten to fifteen seconds in a o.i per cent, aqueous solution of 
eosin, washed, and then the methylene-blue used, a very good 
picture of the acid coloring elements is given. 

Eosin and Methylene-bhie. — Fix the smear in absolute 



LABORATORY TECHNIQUE 245 

alcohol alone or mixed with an equal quantity of ether. 
Stain in a 0.5 per cent, solution of eosin in absolute alcohol, 
to which an equal quantity of water is added, for about five 
minutes without heating. Wash and dry, then counter- 
stain in a saturated aqueous solution of methylene-blue for 
about one minute. Wash again, dry and mount. 

Gives a good picture of the nuclei of the basophilic gran- 
ules and of the malarial organism; eosinophile granules 
stain red; the protoplasm of the polymorphonuclear leuko- 
cytes colors a slight pink, the granules remaining unstained. 



CHAPTER XVII 
BACTERIOLOGICAL METHODS 

CULTURE MEDIA 

These consist of various nutritive substances employed 
for the cuUivation of bacteria. They may be hquid or sohd. 

Bouillon. — This medium is used by itself and also as 
the nutritive basis of certain solid media. It may be made 
up with lean beef or with 3 grm. of beef extract. If the 
former is used is must be freed from fat and gristle and finely 
minced. Five hundred grams of it are mixed with 1000 c.c. 
of water and boiled for about half an hour. It is then filtered 
and to the clear filtrate is added 10 grm. of Witte's pepton, 
5 grm. of sodium chlorid, and enough water to bring the 
quantity up to 1000 c.c. This mixture is boiled till every- 
thing is dissolved, and it is then neutralized, as its reaction 
is very acid. 

The neutralization should be very carefully carried out 
so that the final reaction is slightly alkaline. This is done by 
carefully adding a 10 per cent, solution of caustic soda and 
testing with htmus paper. During this process the solution 
is kept boiling. When the reaction has been obtained filter 
and add enough water to bring the volume up to 1000 c.c! 
The bouillon frequently becomes cloudy on account of a 
precipitate of phosphates. If this occurs, a permanently 
clear fluid may be had by refiltering. 

Glucose bouillon is similar to the above except that it 
contains i per cent, glucose in addition. 

Agar-agar. — To 1000 c.c. of beef bouillon 15 grm. of 
agar-agar are added and boiled for an hour, constantly 
stirring. Water is added at various intervals to keep up the 
required volume. After the boiHng is done the contents are 

246 



BACTERIOLOGICAL METHODS 247 

allowed to cool to 60° C, at which point an egg is beaten into 
the fluid, which is again boiled for about ten minutes. Then 
filter while hot through wet filter-paper. A jacketed filter 
kept warm by a gas flame facihtates the process. As the 
fluid cools while filtering it has to be again heated till all 
passes through. 

The purpose of the agar-agar is to give a medium thai 
will remain solid at a temperature equal to that of the body, 
which is the best for many bacteria. The agar will melt at 
about 42° C. 

Gelatin. — To 1000 c.c. of boiling beef bouillon add 100 
grm. of golden seal French gelatin. When the gelatin is 
thoroughly dissolved boil for about five minutes and neutralize 
by the method described for bouillon. The mixture is 
cooled to 60° C, an egg beaten in, boiled about ten minutes, 
and filtered through wet filter-paper. Should add sufficient 
water to bring the quantity up to the original amount. It 
may have to be re-heated a couple of times before filtration 
is complete. Care must be taken not to bring the mixture 
to the boiling temperature more frequently than is necessary, 
as the power of coagulation may be destroyed. 

This medium melts at temperatures above 22° C. 

Glucose gelatin is gelatin that has been dissolved in 
glucose bouillon. 

Blood-serum {Loeffler's Mixture). — The blood-scrum is 
obtained by collecting it at a slaughter-house. Jars holding 
about a gallon should be used. These should be clean but 
not necessarily sterilized. The collected blood is put aside in 
a cool place for twenty-four to forty-eight hours till the blood 
is completely clotted. If the clot adheres to the side of the 
jar, loosen it with a glass rod. The clear scrum is removed 
with a pipette. This is then mixed with glucose bouillon. 

Glucose bouillon (i per cent.) i part 

Beef blood-scrum 3 parts 

The above is then run into test-tubes to a depth of about 
4 cm. These are placed on an incHne so that they will be 
on a slant when coagulated. In this position they are placed 



248 A MANUAL OF PATHOLOGY 

in a hot-air sterilizer and kept at a temperature between 
85° and 90° C. for an hour. The thermostat should be care- 
fully watched so as to not have the heat vary from the above 
figures. After the medium has become thoroughly coagu- 
lated the tubes are sterilized in steam for half an hour on 
three successive days. 

Litmus Milk. — To milk that has been freed from cream 
enough of a freshly prepared aqueous solution of htmus is 
added to give it a blue color. This is run into test-tubes 
which are treated by intermittent steam sterilization. Fresh 
milk should be used and the process quickly carried out to 
prevent as much as possible the growth of bacteria. 

Potato Cultures. — The potatoes should be thoroughly 
scrubbed with brush and water. Solid cylinders of a size 
to fit the test-tubes are cut with a cork borer. They are then 
split obliquely and the pieces placed in running water for 
some twelve hours. The oblique pieces are then placed in 
test-tubes with the larger end downward. A few drops of 
water should be added to prevent drying. The tubes are 
then put through the fractional steam sterilization. 

Dunham's Pepton Solution. — 

Pepton 10 grm. 

Sodium chloric! 5 grm. 

Distilled water 1000 c.c. 

The pepton and sodium chlorid are dissolved by boiling 
and the mixture filtered. Test-tubes are filled and sterilized. 

Filling of Test-Tubes. — New test-tubes are best cleaned 
by washing in a very weak solution of nitric acid, then rinsing 
in water and allowing to become dry or nearly so. Old tubes 
that have contained cultures are boiled for nearly an hour 
in a 6 per cent, solution of common soda. 

The cleaned tubes are plugged with raw cotton, placed in 
the hot-air sterihzer at 1 50° C. till the cotton has turned brown- 
ish. This is to mold the stopper to the shape of the tube. 

To fill the tubes it is best to take a large funnel and by 
means of a short piece of rubber connect it to a piece of glass 
tubing a couple of inches in length. The supply of the me- 



BACTERIOLOGICAL METHODS 249 

dium is controlled by a pinch-cock on the rubber. The glass 
tube is inserted into the test-tube, the required amount of 
medium run in, and the cotton plug put back. Care should 
be taken not to get any of the culture medium on the neck 
of the tube, as the cotton would stick to it. If ''slant" 
cultures are to be made, run in about 5 c.c. of fluid; if ''stab" 
cultures, about 8 to 10 c.c. should be used. The filled tubes 
are then sterilized. 

Instead of test-tubes, flasks of varying sizes may be used 
to contain the medium. 

Sterilization of Culture Media. — This may be done by 
the intermittent method. In this the media are exposed to 
steam on three successive days for a period of thirty to 
forty-five minutes. A single sterilization will kill all bacteria 
except those that are in the spore stage. These bodies will, 
however, develop within the twenty-four hours into the adult 
form, and are then killed by the subsequent sterilization. 

Instead of the above the autoclave may be used. It is a 
metal chamber so arranged as to allow sterilization under 
pressure. A temperature of 110° C. is obtained, and in it all 
bacteria and spores are destroyed in twenty to thirty minutes. 

After the final stcrihzation if "slant" cultures are to be 
made the test-tubes are so placed that the medium will 
come about half-way up the side of the tube. 

When the media have solidified the tubes can be kept a 
longer time if the cotton is trimmed off and rubber caps put on. 

Sterilization oj Apparatus. — Metal bodies that will not 
be injured, platinum wires, forceps, etc., may be placed 
directly in the flame of a Bunsen burner. Glassware is 
steriHzed by hot air, by steam, or by boiling. Chemical 
sterilization is not often employed. 

Forms of Cultures.^ 

1. Slant. 

2. Stab. 

3. Petri dish. 

4. Esmarchtube. 

5. Hanging drop. 

6. Anaerobic. 



250 A MANUAL OF PATHOLOGY 

1. Slant cultures: A platinum wire is taken and heated 
in the flame. When cool it is inserted into the material to be 
examined. Then without touching anything, not even the 
sides of the tube, the point of the wire is carefully drawn over 
the surface of the medium and the wire again steriHzed. 
When the cotton plug is removed, the end of the tube should 
be passed through the flame. Care should be taken at all 
times that the platinum wire is carefully sterilized before 
being laid anywhere. 

2. Stab cultures are made by carefully inserting the plati- 
num wire, which should be straight, into the center of the 
culture media. The same precautions as mentioned above 
should be observed. 

3. The Petri dish consists of a shallow glass dish with a 
cover. It is used to a large extent for the purpose of isolating 
colonies and obtaining pure growths. The tubes inoculated 
directly from the material examined usually contain several 
varieties of organisms. The method of isolating is as 
follows : Three tubes of agar-agar or gelatin are melted and 
then placed in a water-bath at a temperature between 40° 
and 42° C. A platinum wire with a small loop at the end is 
inserted into the infected substance and then a tube is inocu- 
lated. From this tube a loopful is carried over to tube No. 
2, and a third tube is inoculated from the second, the platinum 
wire being sterilized each time. Three sterile Petri dishes 
are taken and a tube is inserted under the cover of one and 
its contents poured out. This is done with all three, care 
being taken to have the medium evenly distributed over the 
bottom of the dish. They are then grown twenty-four hours. 

The first tube will contain so many organisms that 
Petri dish No. i will be covered with colonies. The second 
tube, being diluted, will give fewer colonies on dish No. 2, 
while dish No. 3, obtained by pouring out tube No. 3, will 
have only a few scattered colonies. From this last dish the 
individual growths may be removed with a sterilized platinum- 
needle and inoculated into a fresh tube, a pure culture thus 
being obtained. 

4. The Esmarch tube is made by taking an inoculated tube 



BACTERIOLOGICAL METHODS 25 1 

of melted agar or gelatin, laying it on a block of ice, and 
rotating till the medium is distributed in a thin coat on the in- 
side. Care must be taken that the contents do not come 
in contact with the cotton plug. This method has been 
practically supplanted by the Petri dishes. 

5. Hanging drop cultures are obtained by taking a slide 
in which there is a depression and a ring of vaselin is made 
around it. A sterilized cover-glass is taken, a drop of bouillon 
placed on it, and this is inoculated with the usual precautions. 
The cover-glass is inverted over the depression in the slide 
and pressed down upon the vaselin. This is put in the in- 
cubator for twelve to twenty-four hours and then examined. 

6. Anaerobic cultures may be made in various ways. A 
test-tube half full of solid medium is inoculated while still 
fluid or by a deep stab inoculation when cold. The bacteria 
in the deeper portions will be without air. Melted paraffin 
or oil may be poured in the tube to keep out air. PyrogaUic 
acid in combination with strong sodium hydrate is also used. 
The oxygen within the tube may be replaced by an atmos- 
phere of hydrogen and the tube then sealed. 

STAINING BACTERIA 

Staining Cover-glass Preparations.— A well-cleaned 
cover-glass has a small portion of the material for examina- 
tion spread out on it in a very thin layer by means of a 
sterilized platinum wire. The preparation is allowed to 
dry; is best not to do it over a flame. When dry the cover- 
glass is passed rather slowly three times through the flame of 
a Bunsen burner. This coagulates the albumin and prevents 
the material being w^ashed off during the process of staining. 
The cover-glass is covered with the stain and gently warmed 
for fifteen to twenty seconds over a small flame. The speci- 
men is then washed in water, dried by blotting and by gently 
warming, and mounted in balsam. 

Various of the anilin colors are the ones chiefly used in 
bacterial staining. They may be used alone or in combina- 
tion with certain reagents employed to increase the staining 
power. 



252 A MANUAL OF PATHOLOGY 

Saturated alcoholic solutions of the stains should be kept 
in stock and from them the dilute aqueous solutions can be 
prepared. These latter, however, do not keep well, so 
various standard preparations are usually kept on hand. 

Loeffler's Methylene-blue. — 

Sat. ale. sol. methylene-blue 30 c.c. 

Caustic potash in water, 1:10,000 100 c.c. 

This keeps a long time and stains rapidly. 
Gabbet's Methylene-blue.— 

Methylene-blue 2 gm. 

Sulphuric acid 25 c.c. 

Water 75 c.c. 

This is employed as a contrast stain and a decolorizer 
for tubercle bacilh. 

Carbol-fuchsin. — 

Sat. ale. sol. fuchsin 10 c.c. 

5 per cent, watery sol. carbolic acid 90 c.c. 

This stain is very permanent and is useful for many pur- 
poses. Is employed in the differential diagnosis of tubercle 
bacilh. In this method (Ziehl-Nielson) the cover-glass or 
slide is covered with the above stain and heated, till steam 
rises, for about three minutes. Care must be taken not to 
boil the stain, and to replace the solution as it evaporates. 
Wash thoroughly in water and then decolorize with about a 
10 or 15 per cent, watery solution of nitric or sulphuric acid. 
Wash again in water and counter-stain for a minute in Loef- 
fler's methylene-blue. The tubercle bacilli will appear as 
minute red rods; all other organisms will be blue. 

Anilin Gentian-violet. — 

Sat. ale. soL gentian-violet 16 c.c. 

Anilin water 84 c.c. 

AniHn water is made by taking: 

Anilin oil 5 c.c. 

Distilled water 95 c.c. 



BACTERIOLOGICAL METHODS 



253 



Shake thoroughly till a milky fluid is obtained ; then filter. 

This stain should be freshly prepared when needed, as 
it does not last more than ten days. 

. Gram's Method. — After the cover-glass has been 
smeared and fixed it is stained in : 

1. Anilin gentian- violet thirty seconds. 

2. Washed in water two or three seconds. 

3. Put in Gram's solution, as follows, for thirty seconds ; 

lodin I gm. 

Potassium iodid 2 c.c. 

Water 300 c.c. 

4. Washed in 95 per cent, alcohol till the color ceases 
to come out of the preparation. 

5. Dry by blotting and in air and mount in balsam. 
The value of this method lies in the fact that certain 

bacteria will retain the stain while others give it up. The 
bacteria stain dark blue or black while the nuclei are only 
faintly colored. Nuclei that are undergoing division may 
stain rather deeply. 

An organism is said to stain by Gram's method when it is 
not decolorized. This power is made use of to differentiate 
certain organisms that may resemble each other in size and 
shape. 

The more important pathogenic bacteria are divided as 
follows, according to their reaction to Gram's: 



Stained by Gram's Method. 

Staphylococcus pyogenes. 

Streptococcus pyogenes. 

Streptococcus capsulatus. 

Actinomycosis. 

Bacillus anthracis. 

Pncumococcus. 

B. diphtherise. 

B. leprae. 

B. tuberculosis. 

B. tetanus. 

B. aerogenes capsulatus. 



Decolorized by Gram's Method. 

Gonococcus. 
Bacillus typhosus. 
B. coli communis. 
B. malignant oedema. 
Spirillum of Asiatic cholera. 
Diplococcus intracellularis menin- 
gitidis. 
B. pyocyaneus. 
B. of influenza. 
B. of dysentery. 
B. of bubonic plague. 
B. of glanders. 
Spirochaeta of relapsing fever. 



254 A MANUAL OF PATHOLOGY 

METHODS FOR STAINING SPORES 

Spores are the resting forms of various organisms and are 
stained with difficulty, but when once stained are hard to 
decolorize. 

Abbott^s Method.— 

1. Stain the cover-glass deeply with methylene- 

blue, heating till the solution boils. 

2. Wash in water. 

3. Wash in 95 per cent, alcohol, containing 0.2 to 

0.3 per cent. HCl. 

4. Wash in water. 

5. Stain for eight to ten seconds in anilin-fuchsin 

solution. 

6. Wash in water, dry and mount. 

The spores are stained blue, the bodies of the bacteria 
red. 

Moeller*s Method. — 

1. Wash the cover-glass for two minutes in chloro- 

form. 

2. Wash in water. 

3. Place in a 5 per cent, watery solution of chromic 

acid for one-half to two minutes. 

4. Wash in water. 

5. Stain with carbol-fuchsin for one minute, heating 

the solution slowly till it boils. 

6. Thoroughly decolorize in a 5 per cent, solution 

of sulphuric acid. 

7. Wash in water. 

8. Stain in aqueous methylene-blue (i gram to 100 

c.c.) for thirty seconds. 

9. Wash in water, dry and mount. 
The spores will be red and the bacteria blue. 

STAINING OF FLAGELLA 

Loeffler's Method.— 

I. Flood the cover-glass with the following solution, 
which should be filtered before using : 



BACTERIOLOGICAL METHODS 255 

20 per cent, aqueous solution of tannic acid 10 c.c. 
Cold saturated solution of ferrous sulphate 5 c.c. 
Saturated aqueous or alcoholic solution of 

gentian-violet or fuchsin i c.c. 

This is very gently heated, not boiled, for about 
one minute. 

2. Wash in water. 

3. Stain in anilin gentian-violet or anilin-fuchsin 

with gentle heating thirty to sixty seconds. 

4. Wash, dry, and mount. 

BowhilPs Method. — Stain the cover-glass in the follow- 
ing solution, heating gently for ten to fifteen minutes: 

Saturated alcoholic solution of orcein 15 c.c. 

Aqueous solution of tannin (20 : 80) 10 c.c. 

Distilled water. 30 c.c. 

Filter the mixture before using. The orcein stain should 
be at least nearly two weeks old. 

In staining sections for bacteria Gram's method or that 
used for the tubercle bacillus is generally employed. Better 
results arc obtained with paraffin sections, but celloidin may 
be used. 

Staining Capsules.^ 

1. Cover the preparation with glacial acetic acid for a 

few seconds. 

2. Drain off (do not wash) and replace with anilin gen- 

tian-violet. Pour this off and add more stain till 
all of the acid has been removed. 

3. Wash in a 2 per cent, solution of sodium chlorid 

and examine in the same. 



PART II— SPECIAL PATHOLOGY 



CHAPTER XVIII 
THE BLOOD 

Blood is composed of two parts, the cellular elements, 
and the fluid or liquor sanguinis. Is alkaline in reaction, its 
specific gravity is about 1.055, ^.nd it has a characteristic odor 
in different animals. 

The arterial blood is freshly aerated and is bright red in 
color, venous blood is bluish and does not contain oxygen, 
while capillary blood is intermediate. 

The gaseous constituents and their proportions are as 
follows : 

Arterial. Venous. 

Oxygen 21.6 6.8 

Carbon dioxid 40.3 48.0 

Nitrogen 1.8 1.8 

Erythrocytes. — Are bi-concave discs of an average diam- 
eter of 7.2 to 7.8/^ and are non-nucleated in their normal con- 
dition. Are very elastic, and are short-Hved. Their function 
is to carry oxygen from the lungs to the tissues. They may 
vary greatly in health in both size and shape. Microcytes 
when below 4 fi] megalocytes or macrocytes when above 10 fi\ 
these latter are found in pernicious anemia. Poikilocytes, 
those cells whose shape is much changed, usually pear- 
formed or stellate. When many are found the condition is 
known as poikilocytosis. Occur in severe anemias. At 
times may be nucleated. Normoblasts are nucleated reds the 
size of the usual erythrocytes. Are supposed to be corpuscles 

256 



THE BLOOD 257 

that have been sent out before they have become fully 
matured, indicate an attempt at rapid regeneration. Meg- 
alohlasts are those from 9 to 14// in diameter. Nuclei may 
be multiple, may show degenerative changes. Micro- 
hlasts are those from 2 to 5 jy.. 

Variations in number of the red cells are not uncommon. 
Normally have in a cubic milHmeter five million in the male 
and four and a half milhon in the female. The number is 
diminished in women during menstruation, child-birth, and 
lactation. There are also variations during different times 
of the day. May be relatively increased when the blood is 
concentrated, as in profuse diarrheas; is called polycythemia. 
When decreased, as after severe hemorrhages, is known as 
oligocythemia. 

According to Cabot, it takes from fifteen to thirty days to 
regenerate a loss of 4 per cent, of the blood in the body. 

Hemoglobin.— The amount of the coloring-matter may 
be much diminished by loss of erythrocytes or by each cell 
containing less than its normal amount. Cells that have 
lost all their coloring-matter are known as shadow corpuscles. 
Diminution in amount is known as oligochromemia. Some- 
times the hemoglobin may be dissolved in the plasma, hcmo- 
glohinemia. Occurs in various forms of poisoning as a result 
of destruction of the erythrocytes. 

The amount of hemoglobin may be estimated in various 
ways by special instruments devised for the purpose. Its 
presence is recognized by the spectroscope. For the latter a 
I per cent, solution is used. This also shows the form pres- 
ent. Methemoglohin gives a chocolate color to the blood; is 
seen in potassium chlorate poisoning. In carbon monoxid 
poisoning the blood is a cherry-red. Is dark in color in car- 
bon dioxid poisoning. 

Leukocytes. — Are nucleated blood-cells that do not con- 
tain hemoglobin and vary in size from 5 to 10 //. Usually 
have about 8000 in a cubic millimeter. 

They may be divided as follows according to the way in 
which they react to stains, especially Ehrhch's: 

The polymorphonuclear or neutrophilc leukocytes con- 
17 



258 A MANUAL OF PATHOLOGY 

stitutc about 70 per cent, of the white cells. They are about 
10 //. in diameter and have nuclei that appear lobulated. 

The cytoplasm contains small granules that stain purple 
or violet. These cells possess the power of ameboid motion 
and are also phagocytic. 

The small lymphocyte is about the size of a red cell and 
has a round nucleus that almost competely fills the cytoplasm. 
Forms about 20 per cent, of the leukocytes. Does not con- 
tain granules. Is not ameboid. 

The large mononuclear lymphocyte closely resembles 
the small, but it is slightly larger and contains a nucleus 
that is more oval and which docs not stain so deeply as in the 
small variety. This form constitutes from 2 to 4 per cent, 
of the leukocytes. It also contains more cytoplasm than dose 
the small. 

The transitional cell resembles the large mononuclear 
except that the nucleus is indented. It apparently represents 
a transition stage between the large lymphocyte and the 
polymorphonuclear leukocyte. Constitutes from 2 to 4 per 
cent. 

The eosinophile is a leukocyte that is characterized by the 
presence in the cytoplasm of large coarse granules that stain 
deeply with eosin. The nucleus is usually polymorphic. 
Are ameboid. Constitutes from 0.5 to 4 per cent. 

The basophiles are very seldom found. Cytoplasm con- 
tains fine granules that stain with basic anihn dyes. May be 
mononuclear or polymorphonuclear. Are known as "mast" 
cells when large, coarse, basophilic granules are present. 

The myelocyte is a bone-marrow cell that is never seen in 
the normal blood. It is usually somewhat larger than the 
leukocyte and contains a large round or oval nucleus that stains 
very faintly. In the cytoplasm are large numbers of neutro- 
philic granules, as a rule, although in some cases they may 
show a marked affinity for eosin. 

There may be marked variations in the number of leuko- 
cytes. Increase of the polymorphonuclear is called leuko- 
cytosis. Lymphocytosis, an incredise oi lymphocytes; eosino- 
philia, of eosinophiles. 



THE BLOOD 259 

Leukocytosis is a temporary condition, seen normally in 
the new-born, in pregnancy, after cold baths, and about 
three hours after eating. 

Pathologic leukocytosis is seen particularly as a result 
of infection by pyogenic bacteria. In croupous pneumonia 
may get as high as 100,000 per cubic millimeter. Occurs after 
hemorrhages, in malignant disease, and just before death. 

Lymphocytosis occurs in marasmus, syphilis, phthisis, 
in anemia, scurvy, and leukemia. 

Eosinophilia is found most marked in parastitic diseases, 
gonorrhea, sarcoma, gout, bronchial asthma, disturbances 
of the sympathetic system, and in some forms of leukemia. 

Leukopenia indicates a diminution in the number of 
the leukocytes. 

Blood plates or placques are small, oval or round, 
colorless and flat bodies, seldom more than 3 [i in diameter. 
They are very viscid, are of high specific gravity, and are 
thought to be important in the formation of fibrin. Esti- 
mated at from 1,500,000, to 5,000,000 per cubic millimeter. 
Stain readily with anilin dyes. May be formed from ery- 
throcytes. 

DISEASES OF THE BLOOD 

Pernicious anemia is a condition in which the amount of 
hemoglobin is diminished as well as the number of red cells 
and there appear in the blood many malformed erythrocytes. 

Frequently the cause is unknown, but in some cases it 
may result from the presence of intestinal jjarasites, as the 
dibothrioccphalus latus or the uncinariaduodenalis. It may 
occur as a result of numerous hemorrhages, of gastric car- 
cinoma, and of infectious diseases. 

The blood shows a marked diminution of erythrocytes, 
often as low as 1,000,000 or even 143,000; the hemoglobin 
is considerably reduced, 30 to 35 per cent., but the relative 
amount in each cell is high. 

There are marked changes in the siz.e of the erythrocytes, 
megalocytes being very numerous, also in shape, poikilocyto- 
sis. Nucleated red cells occur in quite large numbers, 



26o A MANUAL OF PATHOLOGY 

megaloblasts particularly, although in some cases normo- 
blasts predominate. The nuclei are frequently degenerated 
and generally show polychromatophilia. 

The leukocytes are little involved until toward the fatal 
termination, when there may be extreme leukocytosis. 




— L 



/ 



Fig. III. — Pernicious Anemia (Cabot). 
L, L, Lymphocytes; m, m, m, m, megaloblasts; cover-slips stained with 
Ehrlich's triacid, and drawn with camera lucida. 

Coagulation is sHght, specific gravity is low, 1.028, and 
there is httle tendency to form rouleaux. 

The chief lesion of the tissues is an extreme fatty degenera- 
tion. The bone-marrow is red, soft, and frequently shows 
areas of hemorrhage. Microscopically nucleated red cells 
are seen in great numbers. 

In the spinal cord degeneration of the posterior col- 
umns has been recognized. 



THE BLOOD 26 1 

Chlorosis is a blood disease occurring mainly in girls at 
the age of adolescence. It is characterized by a great reduc- 
tion in the amount of hemoglobin without a corresponding 
reduction in the number of erythrocytes. 

The cause is unknown. In some cases hypoplasia of the 
arterial system and of the genitaha has been observed. 



,*,>/- 

•v^^-' 










Fig. 112. — Myelogenous Leukemia (Cabot). 
a, Eosinophilic myelocytes; b, "mast-cell"; e, e, e, ordinary eosinophile; 
;;?, 7n, myelocytes; n, n, normoblasts; p, p, polynuclear ncutrophiles; r, r, 
Reizungsformen (Tiirck) (cover-glass film stained with Ehrlich's "triacid" 
and drawn with camera lucida). 

Nervousness, heredity, poor hygiene, and auto-intoxication 
from intestinal disorders have been alleged. 

The blood is very pale, the number of red cells getting as 
low at times as 3,000,000, with from 40 to 30 per cent, of hemo- 
globin. The erythrocytes are very pale in the center, fre- 
quently show poikilocytosis, and may at times contain nuclei; 
normoblasts as a rule, megaloblasts are seldom present. 



262 A MANUAL OF PATHOLOGY 

Changes in the leukocytes are unusual. 

Leukemia is a disease of the blood-producing structures, 
It is characterized by a permanent increase in the leukocytes, 
other than the polymorphonuclear variety, and by lesions of 
the bone-marrow and lymphoid tissues. 

The cause is unknown. 

According to the type of leukocyte predominating in 
the blood leukemia may be myelogenous, lymphatic^ or mixed 
when the two varieties are present. 

^ S . ) . 



( 
rs 



Do 



.,J 



\ 



O" 






'-"N 



/ 






Fig. 113. — Lymphatic Leukemia (Cabot). 
/, /, /, /, /, Lymphocytes; p, polynuclear neutrophile; r, r, r, red cells. 

The organs involved are the spleen, bone-marrow, and 
lymphatic nodes. There is marked infiltration of leukocytes 
and a hyperplasia of the lymphoid tissue. The spleen is 
much enlarged and shows grayish circumscribed areas. The 
marrow of the long bones loses its yellow color and becomes 
dark red. Numerous nucleated erythrocytes and eosinophils 
are present. 

The blood is pale and the specific gravity lowered. Co- 



THE BLOOD 263 

agulation is slow. The chief changes are in the leukocytes, 
which may number from 100,000 to 300,000 per cubic milli- 
meter, or even up to 1,000,000. 

The erythrocytes are reduced to about 3,000,000, the 
hemoglobin decreased and many contain nuclei. Is also 
som'e change in size and in shape. 

In the spleno-medullary (myelogenous) type the myelo- 
cytes are present in great numbers, constituting from 20 to 
60 per cent, of all leukocytes. The total number is about 
450,000 per cubic millimeter. The main form is the large 




Fig. 114. — Hodgkin's Disease (Stengel). 
Showing marked enlargement of the glands of the right axilla, with 
consequent dropsy of the arm; less marked involvement of the submaxillar}' 
and cervical lymph-glands. 

mononuclear cell containing neutrophilic granules. The 
nucleus may be central and well staining or cxccntric and 
pale. This latter is seldom found in any condition other 
than leukemia. The ncutrophile granules may be entirely 
lacking and the nuclei show hydropic degeneration. 

Eosinophilic myelocytes may be found in large numbers, 
varying from 3000 to 100,000 per cubic millimeter. 

Polymorphonuclear neutrophilic leukocytes decrease in 
number as the myelocytes increase. Degenerative changes 
in these cells are very common. They are more cohesive, 



264 A MANUAL OF PATHOLOGY 

the nuclei show karyolysis or rhexis and hydropic degenera- 
tion. 

Polynuclear eosinophiles are common. Lymphocytes are 
not very numerous in this form; constitute about 10 per cent. 
Mast cells are constantly increased in leukemia, but are 
difficult to find. At times may be as numerous as the 
eosinophiles. 

In lymphatic leukemia the lymphocytes constitute from 
80 to 90 per cent, of all leukocytes, which number about 
100,000 or less per cubic millimeter. The lymphocytes are 
usually small, but sometimes the large mononuclear pre- 
dominates, these latter being found more generally in acute 
cases and in children. Myelocytes, eosinophiles, polynuclear 
and mast cells are few. Nucleated erythrocytes very scarce. 

In this form there is marked hyperplasia of the lymph- 
nodes, but the spleen seldom reaches the size that it does in 
the spleno-myelogenous type. 

Changes in the number and variety of the leukocytes 
may vary greatly, either spontaneously or as a result of inter- 
current disease. 

Pseudoleukemia (Hodgkin^s disease) is a condition 
in which there is a progressive increase in size of the lymph- 
nodes, particularly the cervical, without the blood changes 
present in leukemia. The characteristic and typical tissue 
change is a proliferation of the endothelial and reticular cells, 
with the formation of lymphoid and characteristic giant cells. 
Accompanying this is an increase in the connective tissue. 
Eosinophiles are usually present in great numbers. 

The cause is not known. This condition seems to be 
more or less closely related to leukemia and lymphosarcoma. 

Pseudoleukemia infantum (v. Jaksch).— This disease 
occurs in early childhood and is characterized by marked 
anemia, leukocytosis, and swelling of the spleen, liver, and 
lymph-nodes. There is, however, no leukocytic infiltration 
of the tissues. 



CHAPTER XIX 
DISEASES OF THE CIRCULATORY SYSTEM 

DISEASES OF THE HEART 

Congenital malformations may be the result of dis- 
turbances of development or of disease during fetal life. 

There may be complete absence, as in acardiac monsters. 
Imperfect septa between the cavities is the most common 
defect. There may be no septum and a simple heart of 
two cavities, like that of a fish, is formed. If the ventricular 
septum is absent there are tw^o auricles and one ventricle, the 
reptilian type. The auricular septum is often incompletely 
closed, giving rise to a patulous foramen ovale. The heart 
may be completely reversed, lying on the right side of the 
body with the aorta coming from the right ventricle and the 
other vessels correspondingly shifted. Is known as dextro- 
cardia. 

The arterial openings may be much smaller than normal, 
particularly the pulmonary. When the latter occurs there 
is marked cyanosis. If the stenosis is of a high grade the 
pulmonary circulation may be maintained by a persistent 
ductus arteriosus. Gives rise to hypertrophy of the right 
ventricle. 

The valves may vary in number and also in length. 

Diseases of the Pericardium. — May have hydro- 
pericardium, a collection of non-inflammatory transudate 
within the sac. Hemo pericardium, when containing blood 
which gains entrance from rupture of the heart or of an- 
eurysms of the great vessels. If in large amount it causes 
death by mechanically interfering with the contraction of the 
heart. 

Pericarditis may be primary or secondary. In the 

265 



266 



A MANUAL OF PATHOLOGY 



primary there is direct involvement of the pericardium by 
bacteria conveyed through the blood. In the secondary 
the condition results from the extension of inflammation 
from neighboring tissues. 




Fig. 115. — Acute Pericarditis (BramwcU). 

Primary pericarditis occurs in the course of such infectious 
diseases as acute rheumatism, scarlet fever, pneumonia, etc. 
The inflammation may vary greatly, and according to its 






DISEASES OF THE CIRCULATORY SYSTEM 267 

severity various forms of pericarditis are described. There 
is at first a dullness of the serous membrane with later a 
serofibrinous exudate. This may be shght or there may be 
1000 to 2000 c.c. of fluid. The pericardium may become 
thickened, roughened, and covered by a coating of fibrin that 
may be quite marked. At the apex the fibrin is collected 
into strands, giving a villous appearance to the heart, the 
cor villosum. At the base of the heart, where the movements 
are more restricted, there is a "bread and butter" appearance. 

As the serum is absorbed the fibrin may be replaced by 
connective-tissue adhesions until the pericardial sac is 
either partially or completely oh\\icY?^.Qd, adhesive pericarditis. 
As a result of this, marked hypertrophy may ensue and 
also some degeneration of the myocardium. Occasionally 
there is a deposit of lime salts in the organized tissue. 

In the early stage there is microscopically a degeneration 
of the endothehum, which is covered by a layer of fibrin, and 
a round-cell infiltration of the subendotheHal tissue. 

Purulent pericarditis generally results from the extension 
of suppuration of some neighboring organ. It may start as 
a simple inflammation and later on give rise to a purulent 
exudate. The pericardial sac contains more or less purulent 
or seropurulent fluid. The myocardium is usually in- 
volved superficially; it becomes edematous, infiltrated with 
pus, and may undergo fatty degeneration; at times in- 
flammation, myocarditis, may occur. 

Tubercular pericarditis is commonly a part of a general 
miliary infection or it may result from an extension from a 
neighboring lesion of the pleura. The lesions found are 
similar to those occurring in tuberculosis in other parts. 

Milk spots are irregular whitish areas found on the 
external surface of the heart. They probably result from 
constant pressure and are more accurately known as friction 
scleroses. There is a thickening of connective tissue below 
the endothelium. 

Myocarditis or inflammation of the heart muscle is 
usually secondary to infectious conditions elsewhere, partic- 
ularly in pericarditis. May be acute or chronic, diffuse or 
circumscribed. 



268 A MANUAL OF PATHOLOGY 

In the acute circumscribed form numerous small met- 
astatic abscesses are present. Beginning as minute points, 
generally in cases of malignant endocarditis, degeneration 
and necrosis may ensue, so that an abscess cavity the size of a 
cherry may develop. This may perforate into the cavities 
of the heart, into the pericardium, or may form a cardiac 
aneurysm. The abscess may lose its liquid contents, become 
encapsulated or infiltrated with Hme salts. 



Fig. ii6. — Chronic Fibrinous Myocarditis. X 80 (Diirck). 
I, Heart musculature; 2, long connective-tissue fibers between the muscle- 
bundles, containing but ver}- few nuclei and blood-vessels. 



In the acule diffuse variety, as seen in diphtheria and scarlet 
fever, there is a diffuse round-cell infiltration between the 
muscle fibers with proliferation of the connective-tissue cells 
as well. The muscle fibers become granular, opaque, and the 
striations indistinct. They may undergo Zenker's hyaline 
degeneration. If the patient recovers scar tissue may form. 



DISEASES OF THE CIRCULATORY SYSTEM 269 

The heart is soft and friable, and usually lighter in color 
than is normal, and the fibers are easily separated. Dilata- 
tion of the left ventricle is often present. 

In chronic fibrous myocarditis the lesions may be diffuse 
or localized. It may be the result of a former acute diffuse 
myocarditis or it may be secondary to diseases of the coronary 
arteries or to disturbances of their circulation. In the muscle 
are seen spots or streaks of sclerotic tissue. Microscopically 
greater or less amounts of connective tissue are found 
separating the fibers which frequently undergo a fatty degen- 
eration as a result of pressure and thus give rise to irregular 
yellowish areas. 

Some of the sclerotic portions found along branches of the 
coronary artery probably represent healed infarcts. 

Fatty metamorphosis is often found in toxic and infectious 
diseases. Is usually irregular in its distribution, forming 
areas of yellowish tissue, easily distinguished beneath the 
endocardium. In the fibers are found fat granules; the 
striations disappear and the nuclei may show degenerative 
processes. 

Brown atrophy is a condition in which the heart is re- 
duced in size and is brownish-red in color. Is found in old 
age and in chronic cachexias. Within the muscle fiber at 
the ends of the nuclei are found numerous minute brownish 
granules (Fig. 12). 

By endocarditis is indicated an inflammatory condition 
of the serous membrane lining the heart. Is most common 
upon the valves, although the endocardium of the cavities 
may be involved. It may be divided into the acute and the 
chronic; the acute being subdivided into the verrucosc and the 
ulcerative. 

Acute endocarditis is a secondary condition occurring in the 
course of an infectious disease as a result of the action of 
bacteria. It is characterized by the formation of cauliflower 
growths upon the valves or by ulceration of the leaflets. 

It is found particularly in acute articular rheumatism, 
in pneumonia, scarlet fever, ])ucrperal sepsis, and gonorrhea. 
The organisms most commonly found have been the staphy- 



270 



A MANUAL OF PATHOLOGY 



lococcus, Streptococcus, and diplococcus pneumoniae, also the 
gonococcus. 

The most common seats are the mitral valve, then the 
aortic and pulmonary valves. In fetal endocarditis the 
right side of the heart is more frequently involved. Instead 




Fig. 117. — Chronic Verrucose Endocarditis of the Aortic Valves, 

SHOWING THE WaRTY PROJECTIONS FROM ThEIR KdGES. ThE 

Valves are at the Same Time Thickened and Stiffened by 
Sclerotic Changes (McFarland). 



of the edge the lesion first occurs on the line of closure. The 
endocardium becomes opaque and small, irregular nodules 
appear {verrucose endocarditis). These elevations consist 
of layers of fibrin, beneath which is the endocardium, show- 



DISEASES OF THE CIRCULATORY SYSTEM 27 1 

ing desquamation of the endothelium with also round-cell 
infiltration and proliferation of the fixed connective-tissue 
cells. In the masses of fibrin will be found blood plates, 
leukocytes, and frec|uently bacteria. 

The process may terminate by a degeneration of the 
vegetations with the formation of scar tissue and subsequent 
thickening and contraction. There may also be marked 
calcareous infiltration. 

If the condition continues there may be destruction of the 
valve, ulcerative endocarditis. In this there is a superficial 
necrosis of the valve with a deposit of fibrin upon the ulcerated 
surface. As the lesion progresses the leaflet may become 
weakened and distended by the blood-pressure, forming an 
aneurysm of the valve. Perforation may occur and portions 
of the leaflet, or of the fibrin mass may be set free in the blood 
as emboli. These generally contain bacteria, and, lodging 
in the brain, kidney, and spleen, will give rise to metastatic 
abscesses. 

Either of these two varieties may terminate in the chronic 
form. 

In chronic or sclerotic endocarditis there is an over- 
growth of fibrous tissue, usually with calcification, causing 
a distortion of the valves. The leaflets become thickened, 
less elastic, rigid and hard, and frequently shortened. As a 
result the lumen of the orifice may be decreased and give rise to 
obstruction to the flow of blood {stenosis). On account of the 
lack of elasticity the valves arc no longer able to completely 
close the orifice, so there is a backflow of blood {regurgitation). 

There is also frequently present a shortening and thicken- 
ing of the chorda,^ tendinea?, which on account of preventing 
.the valves from closing gives rise to regurgitation. 

This form of endocarditis may be a sequel to the acute 
varieties or it may gradually develop independently of such 
conditions. 

There may also be bits of tissue or fibrin broken off with 
resulting embolism. 

As a result of the disturbances of the circulation which call 
for increased effort, there is hypertrophy of the heart with 
subsequent dilatation. 



272 



A MANUAL OF PATHOLOGY 



CARDIAC HYPERTROPHY 

In this condition there is an increase in both the number 
and size of the muscle fibers. It may be the result of either 
outside interference to the heart's action, as in adhesive 











Fig. 118. — Hypertrophy and Dilatation of the Heart (Bollinger). 

pericarditis; or inside resistance, as occasioned by valvular 
lesions. It also occurs when there is increased resistance to 
the flow of blood, as is found in arteriosclerosis. 

Hypertrophy will, however, occur only when the heart is 
primarily able to overcome the obstacle. If unable to do so, 



DISEASES OF THE CIRCULATORY SYSTEM 



273 



there will be relaxation, dilatation. As a rule, one chamber 
of the heart is chiefly involved, but it is unusual not to find 
other chambers more or less affected. 

When the heart enlarges sufficiently to overcome its ob- 
structions and the circula- 
tion is carried on without 
any apparent trouble, the 
condition is known as com- 
pensatory hypertrophy. 
This may continue for a 
long time, but there finally 
comes a moment when the 
heart is no longer able to 
do its work. The symp- 
toms then of failure of com- 
pensation make their ap- 
pearance. 

According to the location 
of the obstacle different 
cavities of the heart are in- 
volved. In the most com- 
mon valvular lesion, mitral 
regurgitation, there is a hy- 
pertrophy of the left ven- 
tricle. In lesions of the 
aortic valve the greatest 
enlargement may occur, 
giving rise to the "cor bo- 
vinum." Any interfer- 
ence with the systemic cir 
culation will give rise to this 
condition. 

Enlargement of the right 
ventricle arises from interference with the circulation within 
the lung, as in emphysema. 

The hypertrophy resulting from valvular lesions is due 
to the cavity containing a greater amount of blood than is 
normal, whether stenosis or insufficiency or both be present. 
18 




Fig. 119. 



Atheroma of the Aorta 
(Bollinger). 



2 74 A MANUAL OF PATHOLOGY 

If there is stenosis, the entire charge of blood is not pushed 
forward before the heart enters into diastole and receives 
another supply from the auricle. If there is regurgitation 
the ventricle during its diastole receives blood both from 
the auricular and from the distal sides. In either case the 
heart must increase its muscular power before the circulation 
can be properly carried on. 

The hypertrophied heart may weigh as much as looo or 
1500 grm. in extreme conditions, more commonly from 700 to 
800 grm. 

Three forms of cardiac hypertrophy may be described: 

I. Simple hypertrophy, in which there is an increase in 
the thickness of the muscular wall without any diminution in 
the capacity of the cavity. 

II. Excentric, in which there is increase in the size of the 
cavity and in the thickness of the walls. 

III. Concentric, in which there is thickening of the wall 
with diminution in the cavity. This is |)robably a pure 
port-mortem finding, being an arrest in systole of a hyper- 
trophied heart. 

CARDIAC DILATATION 

This may be either actUe, as a result of severe muscular 
exertion, or chronic, following hypertrophy. Consequently 
the walls may be either abnormally thin or correspondingly 
thick. 

Dilatation is due either to a weakening oj the cardiac walls, 
following interferences with nutrition, or to an increase iji the 
cardiac blood- pressure. 

The failure of nutrition is due to interference with the 
coronary arteries. In this the heart walls become soft and 
fiabby. 

Diseases of the Arteries 

Endarteritis, or inflammation of the artery, usually 
results from the presence of foreign bodies, either infectious 
or sterile, within the vessel. It may be caused by organisms 
gaining entrance into the vasa vasorum. The intima is 



DISEASES OF THE CIRCULATORY SYSTEM 275 

first involved; it becomes roughened, the endotheHal cells 
become loosened, and there is usually an infiltration of round 
cells. The vasa vasorum are involved and the inflammatory 
process may extend to the media or the adventitia, and as a 
result a thrombus generally forms within the lumen. 

Periarteritis is an inflammatory condition around an 
artery, usually arising from injuries from without, or some- 
times by extension from within. There is an infiltration of 




Fig. 120. — An Atheromatous Patch in the Abdominal Aorta which 
HAS not yet Broken through (DmitrijclT). 
J, Intima; M, media; A, adventitia; b, atheromatous necrotic focus in 
the intima and media; c, elastic fibers of the intima; d, elastic fibers which 
have persisted between the necrotic focus and the endothelial layer; e, 
thickened endothelium; /, infiltration of the media with small cells. 



the adventitia, which becomes swollen and edematous. The 
media and intima become involved, there is desquamation 
of the endothelium with the formation of thrombi. 

Arteriosclerosis, artcrio-capillary fibrosis, or chronic 
arteritis, is a condition characterized by an increase in con- 
nective-tissue formation accompanied by degenerative changes. 
These may be circumscribed or diffuse. The fibrous forma- 
tion occurs chiefly in the outer coats and is referred to as 



276 A MANUAL OF PATHOLOGY 

sclerosis, the degenerative processes involve the intima and 
are spoken of as atheroma. 

The large vessels such as the aorta are most commonly 
affected, but the arteries at the base of the brain and the 
splenic artery are frequently involved. 

In the circumscribed form, arteriosclerosis nodosa, numer- 
ous small oval or round yellowish-white areas are visible. 
These are but slightly elevated and vary in their consistency 
according to the structure. If there is much connective 
tissue, they may be ^'ery firm; if degenerative changes have 
occurred, they will be soft. 

As as result of the presence of these areas the elasticity 
of the vessel is interfered with, nutrition suffers, and con- 
nective tissue forms. Beneath the intima there will be found 
areas of softened semifluid substance, atheromatous cysts, 
covered by an imperfect layer of endothelium. This cover- 
ing may break off, allow the contents to escape, leaving a cavity 
known as an atheromatous ulcer. The material found with- 
in these so-called cysts is composed of tissue that has under- 
gone a fatty degeneration. Microscopically yellowish gran- 
ules and droplets of fat as well as crystals of fatty acids are 
present. Instead of escaping, the cystic contents may be- 
come markedly infiltrated witli lime, thus forming athero- 
matous plates. 

Whenever an atheromatous ulcer has formed, the wall of the 
vessel at that point may be thinner and less elastic than 
normal. As the elasticity of the vessels is decreased there is 
consequent increase in blood-pressure with hypertrophy of 
the left ventricle. With the increased pressure there occur 
dilatations of the vessel at its weakened points, with the 
formation of aneurysms. 

In the smaller vessels, particularly of the brain, rupture or 
apoplexy quite frequently occurs. 

In difjiise arteritis or arterio-capillary fibrosis the smaller 
arteries and capillaries are the seat of fibrous tissue forma- 
tion. Resulting from this, there may be more or less lessen- 
ing in the lumen of the vessel, endarteritis deformans. 

If the lumen is completely occluded, is known as endar- 



DISEASES OF THE CIRCULATORY SYSTEM 



277 



teritis obliterans. In both cases there will be interference 
with the supply of nutrition and degenerative changes, 
chiefly hyaline, of varying degree consequent. 

These lesions are very common in both syphihs and 
tuberculosis. In the first there is a cellular prohferation 
beginning in the adventitia but ultimately involving the in- 
tima. 

Aneurysm. — An aneurysm is a circumscribed dilatation 
of an artery. It may be (i) true or (2) jalse, according to 




/C/?J^^ , 's^'-\'rr":- '; ' */f/m'''?\ 



f 



'^''^^:^ 



Fig. 121. — Endarteritis Productiva (Diirck). 

whether (i) all the arterial coats are involved or (2) whether 
t here has been a rupture of one or more of the coats. 

Aneurysms may be single or multiple, and may vary 
Lj^rcatly in size. They result cither from injury or disease 
of the vessel or from increased arterial blood-pressure. 

They are classified according to their form. They mav 
be: 

I. Saccular, in which case there is a hemispherical dila- 
tion extending from one side of the artery. 



278 



A MANUAL OF PATHOLOGY 



2. Fiisijorm, a cylindric dilatation extending for some 
distance along the artery. 

3. Dissecting. In this variety the blood passes through an 




Fig. 122.— Aneurysm of the Arch of the Aorta (Bollinger). 



opening in the diseased intima and makes its way between 
it and the media, or between the media and adventitia. 
Occasionally the blood may re-enter the lumen through a 
lesion further along in the course of the vessel. Is most com- 
mon in the large arteries. 



DISEASES OF THE CIRCULATORY SYSTEM 279 

In the brain there is quite frequently found a condition 
known as multiple miliary aneurysms. In the course of the 
small vessels, particularly branches of the lenticulo-striate, 
numeroiis very small dilatations may be found. They are 
probably the result of degenerative changes in the media. 

After an aneurysm has once been formed it may be rendered 
harmless by means of the deposition of layers of fibrin within 
the cavity. This may go on till there is complete obliteration, 
this, however, does not frequently occur. Although an 
aneurysm is a soft structure there may be extreme destruction 
of surrounding tissues, particularly of bone. The pressure 
exerted by the aneurysm shuts off the periosteal blood-supply 
and more or less erosion of the bone follows. 

Ultimately rupture of the sac generally occurs. The walls 
have become so thinned and weakened that they are no 
longer able to resist the pressure. Rupture commonly takes 
place when there has been some unusual muscular exertion. 
It may occur, though, when the individual is quiescent. 

DISEASES OF THE VEINS 

Thrombosis has already been discussed under that general 
heading. 

Phlebitis, inflammation of the veins, may follow inflam- 
matory conditions around the vessel, from traumatism, or it 
may arise from conditions within, by infection from micro- 
organisms circulating in the blood. It may be an acute 
purulent form in which there is first an infiltration of round 
cells, then rapidly of pus cells. This condition follows along 
the vessel, forming abscesses and thrombi. The formation 
of the latter depends upon the loss of integrity of the intima. 
The thrombi act as plugs so as to prevent as well as possible 
the entrance of the invading organisms into the blood, but 
they may break down and send forth innumerable particles 
of infecting material. 

Chronic phlebitis, or phlebosclerosis, is a condition similar 
to arteriosclerosis, but is much less common. In it the 
sclerotic processes predominate, the atheromatous being less 
marked. 



28o A MANUAL OF PATHOLOGY 

Varicose veins are ones in which dilatation has occurred. 
This may take place in the neighborhood of a valve, and by 
rendering it incompetent the blood-pressure is increased. 
In this way the greater part of a vein may be distended. If 
the vessel has become longer than normal it will naturally be 
more tortuous (cirsoid). In this form the various loops 
may come in contact, and at that point undergoing atrophy 
of their walls communications will be established; these are 
known as varices, or varix. Such portions resemble ca^Tr- 
nous or erectile tissue. 

In the dilated portions thrombi may form or a periphlebitis 
with the formation of dense connective tissue take place. 
Phleboliths are also quite common. 

Interference with the venous return seldom leads to as 
severe results as corresponding lesions in the arteries. This 
being due to the readiness with which collateral circulation 
can be established. Varicose veins are most common in the 
lower extremities. There is generally edema present, and 
if a skin surface is involved extensive ulcerations may form. 
These ulcers heal with difficulty on account of the poor 
nutrition. Another result of venous congestion is the forma- 
tion of dense connective tissue. 

The varicose condition is the result of disease of the vessel 
wall or of increased venous pressure, brought about by in- 
terference with the return flow. This is well seen in the 
long veins of the lower extremity. 

Special names have been given to varicose conditions of 
certain veins. Dilatation of the spermatic veins is known as 
varicocele; of the hemorrhoidals, as hemorrhoids. 

LYMPHATICS 

Inflammation of the lymph- vessels, lymphangitis, is nearly 
always secondary to bacterial infection. It frequently follows 
superficial injuries, particularly those received in the making 
of autopsies. It appears clinically as reddish streaks ex- 
tending from the point of infection. The inflammation may 
go so far as to involve distant lymph-nodes, which become 
swollen, tender, and sometimes suppurate. 



DISEASES or THE CIRCULATORY SYSTEM 281 

The lymph- vessels may become dilated, lymphangieciasis. 
Is usually due to obstruction by parasites. Is found in 
elephantiasis. 

If there is any defect in the wall of the vessel the lymph 
may escape into an adjoining cavity or upon the surface of 
the body. When it enters the abdominal cavity chylous 
ascites ensues. 

Tuberculosis of the lymphatics, particularly when there 
is tuberculosis of the serous membranes, is common. The 
vessels appear as grayish lines. 

Syphilis commonly involves the lymph-nodes in all its 
stages. 



I 



I 






CHAPTER XX 

DISEASES OF THE RESPIRATORY SYSTEM 

DISEASES OF THE NOSE 

Malformations of varying degrees of severity, from com- 
plete absence to slight cleft lip, may exist. There may be 
no external abnormality, but the lloor of the nasal cavity may 
be lacking, the septum deviated, or there may be complete 
obstruction to one or both nostrils by bony growths. 

Rhinitis or coryza is an inflammatory condition of the 
mucous membrane of the nose. It may be acute or chronic 
and be caused by direct or indirect influences. 

The acute form is generally attributed to cold, but may be 
brought about by exposure to the inhalation of various 
irritating bodies, as ])ollen of flowers or the fumes of various 
chemicals, by the action of micro-organisms, or by vasomotor 
disturbances. 

There is first a condition of hyperemia and dryness of 
the nasal mucosa, which is soon followed by a discharge that 
is serous, seromucous, or mucopurulent in character. This 
may cause excoriation of the tissues that it comes in contact 
with. In the discharge are found epithelial cells and leuko- 
cytes as well as bacteria. 

Chronic rhinitis usually follows repeated attacks of the acute 
form, but may be due to some abnormality of the nose itself. 
It may be of two forms, the hypertrophic and the atrophic. 

In the hypertrophic variety there is congestion of the veins 
with thickening and swelling of the mucosa. The mucous 
glands increase in size, there is a thick, viscid secretion, and 
the nasal passages are much obstructed, particularly by en- 
largement of the lower turbinated bones. There is also a 
hyperplasia of the connective tissue. 



DISEASES OF THE RESPIRATORY SYSTEM 283 

The atrophic form may follow in the course of the hyper- 
trophic. The hyperplastic fibrous tissue shrinks, the epithe- 
Hum of the mucosa and the glands are destroyed, and there 
is a secretion of a yellowish purulent matter. This latter has 
an extremely disagreeable odor; the condition is termed 
ozena. The bony septum may even be destroyed. In the 
discharge saprophytic organisms as well as others may be 
found. 

Diphtheria may involve the nasal mucosa primarily, but 
usually is secondary to the pharyngeal form. In it there is a 
pseudo-membrane formed and the organism of diphtheria 
can be found. 

Syphilis generally occurs in the form of a coryza that does 
not differ from that arising from other causes. In the later 
stages ulceration with necrosis of the bones may occur. 
Gumma situated within the periosteum or perichondrium 
may form. This is often followed by destruction with the 
sinking in of the bridge of the nose. 

Tuberculosis may give rise to ulceration with subsequent 
necrosis. In the disdiajges the tubercle bacilli can be 
demonstrated. f^xJi^ituuilZtf^ xTL^kAt^ 

Leprosy is said to be first demonstrable in discharges com- 
ing from ulcerations of the nose. 

Glanders may be conveyed from a diseased horse to the 
nasal mucosa of man and give rise to nodules or farcy buds. 

Tumors. — ^The most common form is that known as a 
polyp. Polyps are composed of fibrous tissue, that is 
generally myxomatous, and a covering of mucous membrane. 
These growths may be mucous, adenomatous, cystic, or 
telangiectatic. 

Various forms of connective-tissue tumors, as the fibroma, 
chondroma, osteoma, and sarcoma, occur. The fibroma 
may give rise to severe hemorrhage if it is highly vascular. 
The sarcoma is the most common malignant tumor. It may 
arise from the septum, but more frequently it extends from 
the antrum. 

Carcinoma is not so common, but epithcHomata may 
develop at the junction of the skin and mucous membrane. 



284 A MANUAL OF PATHOLOGY 

Chondritis and perichondritis are inflammations of the 
cartilages of the larynx secondary to ulcerations of adjoining 
tissues. The cartilages, being very poorly supplied with 
blood, have their nutrition interfered with by the inflamma- 
tory conditions and degenerative changes ensue. In old 
age the cartilages may undergo calcification. 

DISEASES OF THE LARYNX 

Malformations of the larynx are neither numerous nor 
specially important. The parts may be unsymmetric or 
there may be a fistula resulting from the imperfect closing of a 
branchial cleft. 

Acute laryngitis or inflammation of the larynx results 
from exposure to cold, from inhalation of irritating vapors 
and substances, or is due to infections secondary to disease of 
the mouth, pharynx, or lung. It begins with a congestion and 
swelling of the mucosa. This is followed by increased se- 
cretion with disturbances of the voice due to involvement of 
the vocal cords. There is a round-cell infiltration of the 
tissue with sometimes ulceration, in the heahng of which 
scar tissue forms. s 

Chronic laryngitis often follows acute attacks or it may 
develop independently. In it there is dilatation of the 
vessels and hypertrophy of all the portions of the mucosa. 
There is a slight thick secretion and the membrane looks 
distinctly granular on account of the swollen glands, granular 
laryngitis. Is generally found in singers and lecturers. 

Edema may occur slowly, as in passive congestion and in 
chronic inflammations, or it may take place very rapidly 
{acute edema oj the glottis) as a result of some sudden and 
severe inflammatory process, as from the inhalation of steam, 
gases, or the action of irritating substances. In it there is a 
serous infiltration of the ar\'tenoid cartilages and the aryteno- 
epiglottic folds. These swollen tissues meet in the middle 
and more or less completely obstruct the passage of air into 
the lungs. 

In diphtheria of the larynx, which may be primary or 
secondarv' to that of the pharynx, there is an acute inflamma- 



DISEASES OF THE RESPIRATORY SYSTEM 285 

tory process with marked exudation. This contains much 
fibrin and, undergoing coagulation, forms a pseudo-mem- 
brane. In it, besides the fibrin, are found pus cells, des- 
quamated epithelium, bacteria, and sometimes a few red cells. 
This membrane is grayish in color, tough, and when removed 
leaves a raw bleeding surface. 

It may occur as an extensive layer over the larynx or in 
isolated areas. It may be removed, but reproduces very 
rapidly. 

Although membrane is more commonly caused by the 
diphtheria bacillus, it may result from streptococci or from 
the action of irritating vapors. 

Tuberculosis of the larynx is quite common as a primary 
lesion, usually being an infection on top of a chronic in- 
flammation. It generally appears in the form of scattered 
miliary tubercles which frequently break down and ulcerate. 
This occurs rapidly on the vocal cords. The lesions are most 
common about the posterior commissure, the arytenoid 
cartilages, and the true vocal cords, seldom on the epiglottis. 

The ulceration may be very destructive, involving the sub- 
mucosa and even the cartilages, causing inflammation and 
necrosis of them. 

The larynx may be the scat of the slowly spreading form 
of tuberculosis known as lupus. 

Syphilis may be cither of a mild or a very severe type, 
the commonest form being a simple catarrhal laryngitis with 
infiltration of the mucosa and submucosa. Gumma may 
form, break down, and give rise to extensive ulceration, with 
perichondritis and necrosis. As the healing processes go on, 
large amounts of fibrous connective tissue are formed. These 
undergo contraction with frequently marked deformity. 

Leprosy gives rise to nodular lesions, quite similar to what 
may be found in syphilis. They break down, ulcerate, and 
in healing form large scars. 

Glanders is rarely found. In it there is a cellular infil- 
tration with the formation of suppurating ulcers. 

Foreign bodies of various sorts may gain entrance and 
become lodged in the larynx. 



286 



A MANUAL OF PATHOLOGY 



Tumors.— The most common tumors are the papillomata. 
They vary greatly in size and shape and the greater number 
are of inflammatory origin. They consist of a more or less 
dense framework of fibrous tissue co\'ered by a layer of 
epithehum. These growths may be quite flat and but little 
raised above the surrounding surface, or they may be dis- 
tinctly polypoid. The fibrous tissue may show mucous 
changes, and the glandular structures be distended with 
secretion, so as to form cyst-like growths. 

Small fibromata are sometimes found. Adenomata are 
rare. 

Malignant tumors may occur; of these, the sarcoma is 
very rare. When present, it does not involve the cervical 
lymph-nodes. The epithelioma is more common and may 
arise from either the vocal cords and ventricles or from the 
arytenoid folds and the epithelium covering the cartilages. 

DISEASES OF THE TRACHEA AND BRONCHI 

Malformations of the trachea usually consist of a fistulous 
opening, the resuh of failure of closure of the third or fourth 
branchial cleft. Generally appear along the anterior border 
of the sternomastoid, a little above the clavicle. 

The trachea is the seat of inflammatory processes secon- 
dary to those in the neighboring portions of the respiratory 
system, the larynx, and the bronchi. 

Bronchitis may be either acute or chronic. In the acute 
variety the mucosa becomes congested with swelling, and in 
the beginning secretion is decreased. There is soon an in- 
creased exudation, at first thin and with but few pus cehs, but 
soon becoming thick and tenacious and containing more cells. 

If there is much expectoration of a serous type the condition 
is known as hronchorrhea serosa; if purulent in character, 
hroncho-hlennorrhea. 

The cause of bronchitis is not definitely known; it may 
be infectious in its nature, but it commonly follows exposure 
to cold. 

Chronic bronchitis may follow repeated acute attacks or 
accompany various chronic diseases of the lung, particu- 



DISEASES OF THE RESPIRATORY SYSTEM 



287 



larly in those in which there are marked circulatory dis- 
turbances. The mucosa is much congested, the secretion 
may be scant or plentiful, and there may be distinct pro- 
jections on the walls. Instead of proliferative changes there 
may be atrophy with weakening of the bronchial walls and 
dilatations. 

Fibrinous bronchitis is a condition in which a small area of 
the terminal bronchi and bronchioles are involved. It is 
marked by the expecto- 
ration of a dense yellow- 
ish-white substance 
moulded in the shape 
of the air-passages from 
which it came. The 
larger stalk is usually 
hollow, the smaller 
branches being solid 
and the walls com- 
monly laminated. Al- 
though resembling fib- 
rin it does not give the 
characteristic reaction 
and is evidently inspis- 
sated raucous. In the 
meshes of the bronchial 
cast are leukocytes, 
broken-down epithe- 
lium, and Charcot-Lcy- 
den crystals such as are 
found in asthma. Curschmann's spirals are also found. 
These are collections of fine fibrils twisted like a corkscrew. 
They are present at the end of the smallest branches of the 
cast. 

In diphtheria and in croupous pneumonia there may be the 
formation of a true fibrinous exudate. The mucosa of the 
bronchi is reddened and is more or less completely covered 
by a pseudo-membrane. 

Bronchiectasis, or dilatation of a bronchus, may follow 




Fig. 123. — Large Bronchial Coagu- 
lum; Chronic Fibrinous Bron- 
chitis (Vierordt). 



256 A MANUAL OF PATHOLOGY 

chronic bronchitis in which there has been atrophy and 
weakening of the bronchial wall, or it may be due to an in- 
crease in the air-pressure. The medium-sized bronchi are 
the ones most frequently involved. The enlargements arc 
usually saccular, but may be fusiform or cyhndric. There 
may also be several in the course of a single bronchus. The 
walls may appear of normal thickness, but this is due to 
fibrous tissue formation, as the normal tissues are atrophic. 

In fibroid phthisis the contraction of the new formed 
fibrous tissue may drag upon the bronchi and cause them to 
dilate. 

As the walls become weakened, secretions in large amounts 
may be retained and by their weight cause extensive bron- 
chiectasis. The various dilatations may, on account of 
atrophy of the intervening tissues, communicate. They may 
be filled with secretion, with cyst formation resulting. This 
material may undergo decomposition with subsequent 
gangrene or it may dry up. 

Obstruction of a bronchus may be the result of inflam- 
matory changes within the wall, of tumors or foreign bodies 
inside, or of pressure from the outside. 

Foreign bodies more commonly lodge in the right bronchus, 
and may cause ulceration and pneumonia or gangrene of the 
lung. 

Tumors. — Primary growths are uncommon, but secon- 
dary tumors arc more frequent, particularly carcinomata. 

DISEASES OF THE LUNGS 
Circulatory Disturbances 

Anemia of the lung seldom occurs. Is due to pressure 
causing vascular obstruction. 

Acute hyperemia or congestion may be caused by the in- 
halation of irritating gases or it may be collateral, due to ob- 
struction in some other part of the lung. It is also the first 
stage in inflammations of the lung. The organ is dark red 
in color; on section blood escapes from the cut surf ace. The 
tissue will float in water. 



DISEASES OF THE RESPIRATORY SYSTEM 289 

Chronic or passive hyperemia is generally due to obstruction 
of the pulmonary veins, and is associated with disease of the 
aortic and mitral valves and a weakened condition of the 
circulation. The dependent portions alone may be involved 
— hypostatic congestion. 

The lung in passive hyperemia is dark red in color, firm, 
and crepitation is less than normal. From a cut surface there 
escapes on pressure a frothy purphsh fluid. Resulting from 
the congestion, there is frequently prohferation of the fibrous 
connective tissue, giving rise to cyanotic induration of the 
lung. There is desquamation of the epithelium which con- 
tains pigment that has formed through the destruction of red 
cells. This form of hyperemia is frequently seen post mortem. 

In edema of the lung there is an escape of serous fluid into 
the bronchi and air-vesicles. Is generally found as a result 
of chronic congestion following heart and kidney disease, 
but may follow the inhalation of very hot or very cold air. 
Is also found as a terminal affection in many diseases. The 
lung may be either pale or dark, according to the amount of 
congestion present. Is heavy and boggy, but crepitates, and 
from the cut surface a thin, frothy serum escapes in large 
quantities. 

Hemorrhage from the lung, or hemoptysis, occurs in many 
conditions — trauma, emlx)lism, etc. — but is most common in 
phthisis, particularly in the later stages when ulceration has 
taken place. The blood may be expectorated or part of it 
may enter portions of the lung. These areas do not con- 
tain air, are dark in color, and resemble splenic tissue. 

Hemorrhagic injarction is merely a localized hemorrliagic 
area following obstruction of the arteries by emboh. The 
area is usually just beneath the pleura with its base circum- 
scribed and directed outward, the apex directed toward the 
hilum; is dark red, almost black in color, dense and airless. 
The air-spaces arc filled with erythrocytes and some fibrin. 
Infarcts may be small or large, single or multiple. If in- 
fection docs not take place the tissues may regain their nor- 
mal condition. Usually there is degeneration with subse- 
quent cicatrization, an' irregular depressed scar resulting. 
19 



290 A MANUAL OF PATHOLOGY 

Atelectasis v^r collapse of the lung may be either con- 
genital or acquired. The congenital form occurs in new- 
bom babies who have never breathed, either on account of an 
obstruction to a bronchus or from lack of strength. The 
entire lung or portions only may be involved. Obstruction 
of the upper air-passages by meconium or amniotic fluid will 
cause atelectasis. 

The acquired form develops after expansion has once taken 
place, and may result from pressure from the outside, as in 
pleuritic effusions, neoplasms, etc., or it may follow ob- 
struction of a bronchus with absorption of the contained air, 
the vesicles then collapsing. The involved area varies in 
color, according to the amount of blood present, from a pale 
red to a dark brownish color. The tissue is dense, dry, 
tough, docs not contain air, and will not crepitate; will sink 
when placed in water. If there is much congestion, the tissue 
looks like meat and the condition is termed carnificaiion. If 
the atelectasis has existed for some time, there is prohferation 
of fibrous connective tissue, giving rise to an appearance 
resembhng the spleen, known as splenization. Inflammation, 
with fibrosis and the deposit of lime salts, may occur in the 
involved area. 

Emphysema is a condition of overdistcntion of the air- 
cells with an increased amount of air present in the lung. 
It is due either to a loss of elasticity of the air-cells, to an in- 
crease in the air-pressure, or to both. In interstitial em- 
physema there is rupture of the air-vesicles with the entrance 
of air into the interlobular tissue of the lung, smaU bubbles 
appearing beneath the pleura. 

Acute vesicular emphysema results from forced inspiration. 
In it there is merely over-distention of the vesicles without 
structural alterations. 

In chronic vesicular or substantial emphysema there is 
extensive and permanent dilatation of the vesicles. Is gener- 
ally found in those who suffer from chronic bronchitis and in 
glass-blowers or players of wind-instruments, the important 
factor being obstruction to the expiration. The lung is 
much increased in size, pale in color, and feels like cotton. 



DISEASES OF THE RESPIRATORY SYSTEM 29I 

The loss of color is due in great measure to an actual disap- 
pearance of pigment. The edges are rounded, particularly 
anteriorly and at the apex. The vesicles may be so enlarged 
as to be visible to the naked eye. 

Microscopically the vesicles are seen to be greatly enlarged, 






? . / 




C^ 






Fig. 124.— Emphysema of the Lung. 40 X (Diirck). 
Greatly dilated alveolar spaces, extraordinarily thin alveolar septa, 
deficient in cells and torn at many places so that the several alveoli com- 
municate with one another, i, Interlobular septum; 2, contiguous but 
normal alveoli; 3, dilated and confluent alveoli. 



and the walls much thinned. In many places rupture of the 
walls may be seen with the formation of one large alveolus 
from several smaller ones. As the walls are stretched the 
capillaries become narrowed and may finally be com- 
pletely obliterated. As a result nutrition is interfered with 
and degeneration and atrophy follow. 



292 A MANUAL OF PATHOLOGY 

In this form of emphysema the chest is barrel shaped. 
The pulmonary circulation being interfered with, enlargement 
of the right heart with general venous congestion ensues. 

Senile emphysema is that occurring in old age from 
atrophy of the intervesicular septa. Vicarious emphysema 
is that found in one part of the lung as a result of obstruction 
in some other portion. 

Pneumonia 

Pneumonia, or inflammation of the lungs, can be divided 
into various forms according to the nature of the inflamma- 
tory exudate, to the mode of entrance of the etiologic material, 
and to the portion of the lung involved. Fibrinous pneu- 
monia when the exudate into the air-sacs and bronchioles 
is rich in librin; catarrhal when the exudate contains an al- 
buminous fluid in which are desquamated epithelial cells and 
erythrocytes; purulent when pus cells are numerous; caseous 
when there is cheesy necrosis, and fibrous when there is ex- 
tensive fibrous connective-tissue formation. 

It may be lobar or lobular. 

Aerogenic when the infecting substance is conveyed by the 
air through the bronchi; hematogenic when carried by the 
blood; lymphogenic, by the lymphatics; pleurogenic, by ex- 
tension from the pleura. 

Inspiration pneumonia, when a large amount of infecting 
substance gains entrance by the bronchi. 

Hypostatic, when the blood, on account of weakened 
circulatory efforts, settles in the dependent portions of the 
lung and consolidation takes place. 

Pneumonias may also be acute or chronic. 

Croupous, fibrinous, or lobar pneumonia is an acute 
infectious disease, generally caused by the diplococcus of 
Frankel. It usually involves one or more lobes, an entire 
lung, or rarely both lungs. It is characterized by an exuda- 
tion, rich in fibrin, into the air-spaces and bronchioles. 

Morbid Anatomy. — ^The lower lobe of the right lung is 
most frequently first involved, then the lower left, the apices 
seldom primarily. An entire lobe is generally involved. 



DISEASES OF THE RESPIRATORY SYSTEM 



293 



The course of the disease can be best studied by arbitrarily 
dividing it into three stages — that of congestion, of red and 
gray hepatization, and of resolution. It must be remembered 
that all of these conditions may be present in one lung at the 
same moment. 

Stage of Congestion. — ^The lung is actively hyperemic, 
dark red in color, enlarged, and firm. Is very friable and 
contains but Httle air. The air- vesicles are filled with fluid in 




Fig. 125. — Croupous or Fibrinous Pneumonia, Stage of Red Hepati- 
zation; Stained by Weigert's Method to show the Fibrin Only. 
X 180 (McFarland). 

The blue threads filling the air-cells consist of fibrin-filaments. 



which are found numerous red cells, a few leukocytes and 
epithelial cells. The capillaries are greatly distended. 

Stage oj Red Hepatization. — In this the exudate has under- 
gone coagulation and there is complete absence of air from 
the involved area. The lung is solid and resembles the liver 
in consistency. Is swollen, dark red in color, and pits on 
pressure. From the cut surface, which is quite dry, there 



294 A MANUAL OF PATHOLOGY 

project minute plug-like bodies formed of fibrin, which give 
a granular appearance to the tissue. They are formed by the 
coagulated exudate in the ah'eoli being pushed outward by 
the contraction of the elastic fibers. The pleura generally 
shows some fibrinous exudate. Microscopically the air- 
vesicles are seen to be filled with red cells entangled in a net- 
work of fibrin ; leukocytes and epithelial cells are also present. 
The capillaries are less prominent. The diseased tissue will 
sink when placed in water. 

Stage oj Gray H e pa tizai ion. —With the beginning of this 
stage recovery is indicated. The lung loses its red color and 
becomes gray or yellowish. This is shown microscopically 
to be due to changes taking place within the alveoH. The 
blood-supply being interfered with, the exudate undergoes 
fatty degeneration. The erythrocytes have broken down, 
the fibrin has disappeared, and leukocytes are now present 
in great numbers. The exudate no longer closely adheres to 
the walls, but leaves space for the entrance of air. 

Stage oj Resolution. — ^The broken-down exudate is re- 
moved by absorption and by expectoration. The leuko- 
cytes also carry off much of the debris. The lung becomes 
more moist, is less solid, and crepitation returns. The 
epithelium of the alveoli and bronchioles prohferates and the 
lung returns to the normal. There is sometimes a delay in the 
return of the normal elasticity of the alveolar walls. 

Instead of the lung returning to the normal various com- 
plications may arise. Infection by pyogenic bacteria may 
take place, with abscess-formation. Gangrene may also 
follow, particularly if the circulation is weak. Resolution 
may be delayed and proliferation of connective tissue occur, 
giving rise to fibrous pneumonia. Microscopically there is 
seen an extensive cellular infihration and proliferation. The 
septa become much thickened and masses of connective 
tissue extend into the air-vesicles. In alcohohcs there is a 
marked hemorrhagic tendency. 

There may be serious conditions associated with lobar 
pneumonia. The un involved portions may be emphysema- 
tous and congested, and sometimes edema develops. The 



DISEASES OF THE RESPIRATORY SYSTEM 295 

infecting organism may gain entrance into the blood and 
cause inflammations of the serous membranes, particularly 
endocarditis and pericarditis. Cardiac disturbances may 
occur, probably due to the action of toxins. There is also 
usually some involvement of the kidneys. Leukocytosis is 
generally marked. Tuberculosis may follow the pneumonia. 

The symptoms in this disease would seem to depend more 
upon a toxic condition than upon mechanical obstruction to 
breathing by the filling of the alveoli. This would seem to be 
shown by the fact that on the fall of temperature, the crisis, 
the alarming objective symptoms subside. Yet a physical 
examination made at that time shows no changes in the lung 
itself. 

Death may result from the action of the toxins, from over- 
burdening of the heart, or from some of the associated con- 
ditions, as edema or gangrene. 

Catarrhal pneumonia or bronchopneumonia is an in- 
flammatory condition of localized areas of the lung resulting 
from inflammation of the terminal bronchioles. Is also 
known as lobular pneumonia, on account of involving lobules 
of the lung. Occurs generally in young children and old 
people. It is due in the majority of cases to infection. Is 
most common as a sequel to the infectious fevers that are ac- 
companied by bronchitis, as in measles, whooping-cough, and 
influenza. It also follows the inspiration of particles of septic 
matter, aspiration pneumonia. If there has been hypostatic 
congestion to predispose, hypostatic pneumonia may arise from 
the entrance of infectious particles. 

In bronchopneumonia both lungs are generally difl'usely 
involved, areas of consolidation being scattered throughout. 
On the pleural surface small nodular elevations, dark red or 
slightly reddish-gray in color, are seen. Are smooth on sec- 
tion. These areas are firm, and when separated from the sur- 
rounding tissue will sink in water. The lung in the immediate 
\icinity may be emphysematous, other portions being 
collapsed — atelectasis. Microscopically the alveoli are found 
fo contain an exudate, albuminous in character, in which 
desquamated epithelial cells, leukocytes, and erythrocytes are 



296 



A MANUAL OF PATHOLOGY 



present. There is also a marked round-cell infiltration of the 
septa. The red blood- cells and the leukocytes are not, as a 
rule, found in large numbers unless the infection has been due 
to pyogenic organisms. The exudate may then be hemor- 
rhagic or purulent; in either case gangrene may develop. 

The lung returns to its normal condition through fatty de- 
generation of the exudate with absorption and expectoration. 

Fibrous pneumonia is a chronic condition of the lung 
resuUing from long-continued irritation and is characterized 




Fig. 126.— Lobular Pneumoni.\ (Aspiration). X 8 (Ziegler). 
a, Pleura; b, lung; c, pneumonic areas; d, bronchiole; e, blood-vessels. 



It may be 
origin: (i) 



by an overgrowth of fibrous connective tissue, 
divided into several forms according to its 
Pneumonokoniosis, those due to the inhalation of irritating 
particles; (2) those secondary to the acute pneumonias, 
chronic congestion or atelectasis; (3) pleurogenic, arising 
from chronic pleurisy; (4) those in which there is peribron- 
chial and perivascular connective-tissue formation. 

Pneumonokoniosis is a condition of the lung character- 
ized by the presence of dust particles of various kinds. When 



DISEASES OF THE RESPIRATORY SYSTEM 297 

the fine particles gain entrance, they cause a catarrhal inflam- 
mation of the alveoH. Much of the dust may be expecto- 
rated, but some penetrates the interlobular connective 
tissue, where it may remain or be carried to the lymph-nodes. 
By acting purely as a mechanical irritant, or particularly if 
the particles are not aseptic, a productive inflammation 










Fig. 127. — Catarrhal Pneumonia, showing Desquamated Epithelial 
Cells in the Alevolar Spaces (McFarland). 

with the formation of fibrous tissue results. This occurs in 
both lung and lymphatic tissue. 

Some of the foreign particles may get as far as the lymph- 
nodes in the fissure of the liver, and through involvement of a 
vein the dust can gain entrance into the circulation and be 
deposited in the liver and intestine. 

From the irritation a lobular pneumonia may occur and 



298 A MANUAL OF PATHOLOGY 

even cavities (non-tubercular) form. There is always found 
at post mortem some dust inhalation, the amount depending 
upon the environment of the individual. 

According to the kind of particles inhaled, the condition 
receives various names: Anthracosis, when coal-dust; 
siderosis, metal dust; chalicosis, stone dust. 

Secondary fibrous pneumonia results from an o\'ergrowth 
of the connective tissue of the septa, which become much 
thickened. There is also prohferation involving the alveolar 
exudate. 

The pleurogenic form of fibrous pneumonia results from 
chronic pleurisy. The lung shows numerous large and 
thickened trabecuke of fibrous tissue extending from the sur- 
face deep into the interior of the organ. 

The peribronchial and perivascular forms present an over- 
growth of connecli\e tissue in varying degrees, about the 
bronchi and vessels. A moderate form of this is found in all 
the varieties of fibrous pneumonia. 

Purulent pneumonia is one caused by pyogenic organ- 
isms. In it there is found a purulent and hemorrhagic exuda- 
tion, both in the alveoli and fibrous septa. The infection 
may take place through the bronchi, bronchogenic; the blood, 
hematogenic; or through the lymphatics of the pleura, pleuro- 
genic. 

The bronchogenic variety is most marked in the aspiration 
pneumonias that follow suppurative lesions of the upper air- 
passages. Large and small purulent collections are found, 
both in the alveolar walls and within the alveoli as well. 

The hemalogenic form is secondary to purulent areas in 
other parts of the body. The infectious agents gain entrance 
into the circulation, and as emboli are carried to the capillaries 
of the lung. Becoming lodged they set up secondary 
suppurative changes. Hemorrhagic infarctions are frequently 
found. The central part is necrotic, while around it is found 
a zone of severe infiltration. The entire area may soften, 
break do^^Tl and form cavities. The abscesses quite fre- 
quently evacuate into a bronchus or sometimes into the 
pleural cavity, giving rise to empyema, a purulent pleurisy. 
Gangrene of the lung may occur. 



DISEASES OF THE RESPIRATORY SYSTEM 299 

Pleurogenic pneumonia is a form that has its origin in an 
inflammation of the pleura. Involvement takes place not 
only by contiguity but by extension into the deeper portions 
of the lung by way of the lymphatics — purulent lymphangitis. 
Abscesses of the lung may be caused in the same way by an 
extension of an empyema. The lobules of the lung may 
be separated by bands of suppurating tissue (dissecting 
pneumonia). There is thickening of the surface of the lung 
and of the pleura due to an extensive round- cell infiltration. 

Gangrene. — ^This follows the entrance of saprophytic 
organisms into lung tissue that has undergone degenerative 
changes. The primary necrosis may follow in the course 
of pneumonia, tuberculosis, embolism, and infarction. May 
also result from the aspiration of putrefactive material, as in 
gangrene of the larynx, foreign bodies in the bronchi; ex- 
tension of disease of neighboring tissues, as in carcinoma of 
the esophagus with perforation. 

An idiopathic form occurs in alcoholics and in asthenic 
states. 

The involvement may be either diffuse or circumscribed. 
In the latter, there are usually numerous irregular areas of a 
dark brown, greenish, or black color. They are rather dry, 
and are surrounded by a zone of congestion and edema. 

In the diffuse variety the condition is much more severe. 
It may follow the circumscribed form or occur primarily. 
The gangrene is of the moist variety, the affected area being 
soft, mushy, greenish in color, and having an extremely foul 
odor. 

The broken-down tissue may be expectorated and leave a 
cavity through which blood-vessels and bronchi may pass. 
Generally the vessels are obliterated by means of an arteritis 
with thrombus formation. The artery may, however, be 
destroyed before such a protective measure has taken place 
and severe hemorrhage result. 

General embolism with septicemia frequently occurs. If 
recovery follows the disappeared necrotic tissue is replaced 
by connective-tissue hyperplasia. 

The sputum in gangrene of the lungs is extremely oft'en- 



300 A MANUAL OF PATHOLOGY 

sive and tends to separate into layers — an upper frothy one, 
a middle, yellowish and fluid, and a lower layer that is brown- 
ish and purulent. In the sediment are found particles of 
lung tissue, triple phosphate crystals, margaric acid, pus cells, 
pigment, and fat drops. Numerous organisms of various 
kinds are also present. 

Infectious Diseases 

Tuberculosis. — Is caused by the tubercle bacillus and may 
be cither a local disease or a part of a general involvement. 
The infection may gain entrance to the lungs in three ways: 
by the dUv, aero genie or bronchogenic; by the hlood,^ hemato- 
genic; or by the \ym\)h.-c\\^x\nQh,^ lymphogenic. All three 
methods are finally closely associated. 

Aerogenic Tuberculosis. — ^The tubercle bacilli gain entrance 
by adhering to dust particles. They pass down the bronchi, 
finally becoming lodged upon the mucous membrane of 
either the air-vesicles or the terminal bronchioles. The 
apex of the lung is the portion generally involved at first. 
The bacilli act upon the mucosa as an irritant and set up 
a mild catarrhal inflammation. The alveoli become filled 
with desquamated epithelium and leukocytes. This consti- 
tutes the primitive tubercle. The bacilli may grow in the air- 
cells or may be carried by the leukocytes into the lymphatics, 
so that the original tubercle may be cither alveolar or in- 
interstitial, or, if around the hvonchi, peribronchial. As the 
organisms increase in number there is an increase in the ex- 
tent of the tubercle, thus involving neighboring alveoli. 
These undergo the same changes as the one originally in- 
fected. As this process extends there is destruction of the 
capillary vessels in the tubercles, and as no new ones are 
formed, there is a loss of nutrition. As a result there is 
coagulation necrosis of the central part of the tubercle. 
While this is taking place there is a proliferation of the 
fixed connective-tissue cefls in the structures surrounding 
the diseased area; round-cell infiltration also occurs. 

The tubercle, as it increases in size, approaches and coa- 
lesces with neighboring ones till large areas form. The central 



1 



DISEASES OF THE RESPIRATORY SYSTEM 



301 



portion, showing coagulation necrosis, finally opens into a 
bronchus, escapes, and leaves a ragged cavity behind. 
Blood-vessels will be exposed, and if destruction occurs before 
obstructive endarteritis takes place there will be hemorrhages 
of varying degrees of severity. The bronchus may be evident 
or its walls may have been completely destroyed. 










Fig. 128. — Peribronchial Tubercle of the Lung and Caseous Pneu- 
monia OF THE Adjacent Alveoli (Stengel). 



When communication has been effected between a tubercu- 
lar focus and the outside air secondary infection by pyogenic 
organisms occurs. At the same time the tubercular material 
is carried along the bronchi during the respiratory acts and 
other foci are established. The lymphatics carry the bacilli 
into other parts and there is also involvement of the blood- 



302 



A MANUAL OF PATHOLOGY 



channels. Consequently all three methods of infection are 
being made use of and the entire lung may become converted 
into one mass of broken-down caseous material. 

In the bronchogenic form the caseation is particularly 
marked, while in the hematogenic and lymphogenic the in- 
volvement is more distinctly mihary. Of the caseous, three 




Fig. 129. — Subacute Caseous (Tuberculous) Pneumonia (BollingerV 



different forms are described: The acute caseous or galloping 
phthisis; the chronic ulcerative, and the fibrous or fibroid 
type. This is not an accurate clinical division, as all three 
processes may be present in the same lung. 

Acute caseous tuberculosis occurs most frequently in 
children. The process is usually quite rapid in this form and 



DISEASES OF THE RESPIRATORY SYSTEM 303 

the lung resembles somewhat closely the stage of gray 
hepatization of croupous pneumonia. The infection is 'at 
first lobular, but by extension may involve an entire lobe. 
Either the base or the apex is the seat of the primary focus. 
The cut surface of the lung will show irregular yellowish case- 
ous areas with congestion of the intervening pulmonary tissue. 
The yellowish areas when closely examined will be seen to con- 
sist of bronchi surrounded by caseous material and more or 
less filled with the cheesy exudate. The lumen, as a rule, 
is very rarely obliterated completely. Numerous small ex- 
cavations form, but there is little attempt at fibrous formation. 

If the infection is less severe, there is less confluence of the 
degenerated areas, and instead of a general infiltration, scat- 
tered patches of caseous pneumonia are seen throughout the 
lung. There is also more fibrous growth, some of the areas 
becoming completely encapsulated. 

Chronic ulcerative tuberculosis is the form most generally 
met with. It usually begins in the apices and is characterized 
by the formation of quite extensive cavities. These result 
from degeneration and necrosis of the lung tissue. Several 
cavities may coalesce and form a single large one. A large 
part of the ulcerative process is due to secondary infection 
by pyogenic organisms. The inner surface of the cavities 
is rough and irregular, arteries and strands of lung tissue 
being present. There is fibrous proliferation in the walls, 
while in the cavity itself there is a secretion containing 
broken-down caseous material, pus cells, epithehum, and 
tubercle baciUi and the organisms of the secondary infection. 

The arteries traversing the cavities may be the scat of small 
aneurysms which may rupture and give rise to a fatal 
hemorrhage. 

The heahng processes, although well marked in places, 
are unable, as a rule, to keep pace with the necrosis, and the 
patient eventually succumbs. 

Fibroid Tuberculosis. — ^This may occur as an essentially 
chronic condition or it may follow upon acute processes with 
cavity formation. Surrounding the caseous areas there is a 
proliferation of connective tissue with encapsulation and the 



304 



A MANUAL OF PATHOLOGY 



contained material may become completely infiltrated with 
lime salts. It may be merely surrounded by a capsule, and 




Fig. 130. — Tuberculosis of the Lung (McFarland). 
The upper lobe shows advanced cheesy consolidation with cavity-for- 
mation, bronchiectasis, and fibroid changes; the lower lobe retains its spongy 
texture, but contains numerous milian- tubercles. 



if anything should occur that should cause destruction of the 
enveloping tissue, the caseous material could give rise to 



DISEASES OF THE RESPIRATORY SYSTEM 305 

acute processes, the activity of the tubercle bacillus not 
having suffered by its confinement. 

The newly formed fibrous tissue is, in a way, of distinct 
disadvantage, as by its shrinking it causes distortion with 
diminishment in the size of the lung. 

Hematogenous Pulmonary Tuberculosis. — ^This form 
results from the entrance of the infecting material into the 
blood-stream, and is usually part of a general tuberculosis 
of the body, but it may be Hmited to a single lung. The 
bacilh lodge in the capillaries in the form of emboli and set 
up minute foci of degeneration — miliary tubercles. These are 
small grayish areas formed in the same way as tubercles 
elsewhere. When the lungs are alone involved the condition 
is called miliary tuberculosis oj the lungs. 

Lymphogenic Tuberculosis. — In this the infection gener- 
ally results from the bacilli being carried from the lymph- 
nodes, where they have lodged, into the lung tissue by means 
of the lymphatics. A tuberculous lymph-node may soften 
and discharge into a bronchus, a form of secondary aerogen- 
ous infection. Extension may occur from a tubercular 
pleurisy. In such cases there is frequently associated a 
suppurative lymphangitis. The processes in the lympho- 
genic form are quite similar to the hematogenic variety and 
show tubercle formation. 

A patient recovers from tuberculosis when the lung 
becomes sufficiently immunized to resist further progress of 
the bacilli. In such cases the tubercles will have been en- 
capsulated by new-formed fibrous tissue, isolated and cal- 
cified. 

Tuberculosis of the lungs may be complicated by secondary 
infections elsewhere, particularly of the intestines. This 
results from the swallowing of the infectious sputum and is 
most common in adults. The larynx may be involved in the 
same way. There may be infection of the pleura with the 
formation of adhesions that can interfere very much with 
respiration. Lobar pneumonia may involve the non-tuber- 
cular areas of the lung or emphysema may be present. 
Pneumothorax may be caused by the tubercular process 



306 A MANUAL OF PATHOLOGY 

rupturing into the pleural cavity, with collapse of the lung. 
There is usually an accompanying empyema resulting from 
the infection of the pleura by the discharged material. 
Hemorrhage, hemoptysis, is the most dangerous and common 
complication. It may follow the rupture of a small aneurysm 
or the erosion of a vessel before a thrombus has had time to 
form. It may be slight or very severe. Some of the blood 
may remain within the lung and, forming a good medium 
for the growth of saprophytic organisms, give rise to gan- 
grene. 

The apices are the most common primary seat. This is 
probably due to the fact that their bronchi come off at such 
an angle that they are easily obstructed; that on account of 
being furthest away from the entrance of the blood-vessels 
they are more poorly nourished, and that the apex undergoes 
the least distention during respiration. 

Syphilis. — ^This may be cither congenital, the lungs being 
involved as well as other parts of the body, or it may be ac- 
quired. 

The congenital is the more common and occurs as white 
pneumonia, a diffuse form resembling bronchopneumonia. 
The lungs are whitish in color, completely airless, and firm. 
Microscopically there is a desquamation of the alveolar 
epithehum, an infiltration of leukoyctes, and a connective- 
tissue prohferation in the interalveolar and interlobular 
tissues. There is usually some proliferation of the ad- 
ventitia of the blood-vessels, also of the intima, so that some 
of the vessels may be completely obliterated. 

Gummata may be present in the new-born either alone or 
associated with diffuse lesions; are sometimes found in adults. 
They generally occur near the root of the lung, beneath the 
pleura, and are commonly few in number and more or less 
circumscribed. They frequently undergo caseation, and it 
may be very difficult, if not impossible, to distinguish them 
from tuberculosis, except by staining for the tubercle bacillus. 
These areas present the ordinary microscopic appearances 
of gummata. The blood-vessels, besides showing a thicken- 
ing and a hyaline degeneration, are surrounded by a round- 



DISEASES OF THE RESPIRATORY SYSTEM 307 

cell infiltration. The caseous material may be expectorated 
and the cavity be obliterated by the formation of a cicatrix. 

Glanders. — ^This is very rarely found in the lung in man. 
The Bacillus mallei may gain entrance by inhalation or by the 
blood, following infection of the skin. In the first form 
numerous grayish or yellow nodules, varying in size up to that 
of a pea, are found scattered throughout the lobes. They 
are made up of a mass of round cells and frequently undergo 
caseous degeneration. 

When infection takes place by the blood there is a diffuse 
purulent infiltration of large areas of lung, with the formation 
of abscesses and associated hemorrhagic infiltration. 

Actinomycosis. — Seldom occurs. It may result from 
aspiration of the infecting organism, but is more often a 
secondary condition following actinomycosis of the upper air- 
passages or of the anterior or posterior mediastinum. There 
may be a single focus of infection in the form of a cavity con- 
taining a thick cheesy and purulent material in which the 
characteristic yellowish actinomyccs granules are present. 
The lesions may be more general and nodular, these nodes 
tending to undergo central softening. On account of pro- 
liferation of the surrounding connective tissue they may 
closely resemble tubercles. 

Tumors. — Primary growths in the lungs are unusual; 
secondary ones somewhat more common. Of the connective- 
tissue variety, small fibromata, lipomata, cJwndromata, and 
osieomata are found. Primary sarcoma is more common than 
the above and probably originates within the peribronchial 
lymph-nodes as a small round-cell or spindle-cell tumor. 
May have primary endothcliomata of the pleura with exten- 
sion into the lung. 

Secondary sarcoma of the lung is very common. It occurs 
in nearly every case of primary sarcoma elsewhere. Num- 
erous small scattered nodules are found. These are whitish 
in color and frequently undergo softening. 

Primary carcinoma is very rare, but it may develop from 
the mucous glands of the bronchi or a squamous epithelioma 
from the epitheHum of the terminal bronchi and alveoli. 



308 A MANUAL OF PATHOLOGY 

Secondary carcinoma is not as common as secondary sar- 
coma. It results from emboli of tumor cells lodging in the 
capillaries. May follow extension of an esophageal or 
mammary carcinoma. Sometimes may have secondary 
growths resulting from the inspiration of cellular particles of a 
carcinoma of the mouth or upper air-passages. Such cases 
may be associated with areas of bronchopneumonia. 

Adenomata have been met with and dermoid cysts occasion- 
ally appear. 

In leukemia numerous miliary growths consisting of small 
round cells may be found. They resemble tubercles except 
that they arc somewhat whiter and softer, but do not tend to 
undergo caseous changes. 

Parasites. — Besides the specific organisms mentioned 
various vegetable parasites, as the as pergilius, the mucor, and 
the otdium, may be met. Are found at times in tubercular 
cavities. May give rise to a pneumonomycosis aspergillana. 

Animal parasites such as the lung fluke arc sometimes 
found. It gains lodgment near the root of the bronchi and 
discharges its eggs into the mucopurulent secretion that it 
excites. The eggs are found in the sputum. ]\Iay give rise to 
hemoptysis. The cysticercus celluloso', the strongylus longi- 
vaginatus, monas, cercomonas, coccidia, and psoros perms, may 
all be occasionally found in the lung. 

The most important is the echinococcus. It is usually 
secondary to primary disease of the liver and is most common 
in the lower right lobe. There are one or more cysts which 
may vary greatly in size. As a rule, the cyst occasions no 
symptoms, becoming inspissated and calcified. Sometimes 
it ruptures into a bronchus; in such a case the cystic contents 
will be expectorated and in the sputum characteristic hook- 
lets can be found. An empyema can be caused by the cyst 
rupturing into the pleural cavity. 

DISEASES OF THE PLEURA 

Secondary' involvements are more common than primary 
diseases on account of the relation of the pleura to the lung. 
Active hyperemia is an early stage of pleuritis. 



DISEASES OF THE RESPIRATORY SYSTEM 309 

Passive hyperemia occurs in diseases in which there is in- 
terference with respiration; is most common as a result of 
venous stasis due to cardiac disturbances. Hydrothorax 
may result from it. 

Hemorrhage. If there is extreme congestion petechias 
will be found. Are most marked in death from suffocation, 
but also occur in diseases of the blood and in hemorrhagic 
diatheses. 

Large hemorrhages may result from traumatism, from 
rupture of large aneurysms, from fractured ribs, and from 
maHgnant tumors. 

The blood that escapes into the pleura will not coagulate, 
as a rule, and is slowly absorbed if it has not become infected. 
Adhesions will form to some extent. 

Hydrothorax is a condition in which both pleural cavities 
as a rule contain a watery, straw-colored fluid of a low 
specific gravity that does not undergo spontaneous coagula- 
tion. It occurs in chronic heart and kidney disease as a part 
of a general dropsy. The pleura is frequently opaque and 
lustreless and edematous. The lymph-channels are dilated 
and the endothelial cells may desquamate. From the 
pressure of the fluid the lungs are pushed backward and may 
be so much compressed as to interfere greatly with respiration. 
The lung may be even atelectatic. The effusion may occur 
suddenly, as in carbon monoxid poisoning, or be very chronic. 

Is generally a sHght cfl'usion into the pleural cavities just 
before death. 

Pneumothorax is the entrance of air into the pleural 
sacs. Is the result of accident and is almost invariably 
followed by infection and empyema. It results generally 
from the rupture of a tuberculous lesion, from gangrene or 
abscess of the lung, or from the rupture of an emphysematous 
air- vesicle. May be due to perforating wounds of the chest, 
to the rupture of an empyema into the lung, or from perfora- 
tion of a gastric ulcer. 

With each inspiration air escapes from the lung into the 
pleural sac until the pressure becomes so great as to seriously 
interfere with the expansion of the organ. The lung is pushed 



310 A MANUAL OF PATHOLOGY 

backward and is much compressed. The opposite organ is 
displaced to one side, the diaphragm downward, and the 
intercostal spaces bulge. 

The air may be absorbed, but as a rule infection occurs, 
giving rise to a pyopneumothorax, a combination of air and a 
purulent exudate. 

Pleurisy or pleuritis is an inflammation of the pleura. 
It may be either primary or secondary. Most commonly 
occurs in the course of inflammations of the lung, as in pneu- 
monia, tuberculosis, and gangrene. Also from involvement 
in inflammatory conditions of the pericardium, of the spine, 
the ribs or the chest wall. May be tlic part of a general in- 
fectious process, as acute articular rheumatism, or septicemia. 

Many micro-organisms have been found, as the streptococci 
and staphylococci, colon bacillus, tubercle bacillus, pneu- 
mococcus and many others. 

The involvement may be local or general and, according to 
the ^'ariety of exudate, fibrinous, serofibrinous, purulent, and 
Jiemorrhagic. 

A single case of pleurisy may pass through all the above 
stages. In them all the pleura becomes hypcremic, and 
instead of being smooth and glistening, is rough and dull; 
the two layers of pleura do not glide with ease and an exudate 
escapes into the cavity. 

In fibrinous pleurisy there is soon an exudate of fibrin 
forming a thin yellowish layer on the surface. It may increase 
in thickness and cause the pleural surfaces to adhere slightly, 
giving rise to the so-called ''bread and butter" pleurisy. 
This exudate is composed of flakes and masses of fibrin con- 
taining leukocytes. The endothelium below is thickened and 
in places has desquamated. The sub-endothehal connective 
tissue is infiltrated by round cells and the vessels are congested. 

The exudate may be absorbed completely, but if there has 
been much fibrin formation adhesions of varying density 
result. New capillaries penetrate the fibrin masses, the fibro- 
blastic cells proliferate, and organization takes place. These 
bands, although at first dehcate, soon become very dense. 

They may be so extensive as to cause ahnost complete 



DISEASES OF THE RESPIRATORY SYSTEM 3II 

obliteration of the pleural cavity, or be present in scattered 
areas only. There may be areas on the surface of the pleura 
of marked chronic thickening. 

Serofibrinous Pleuritis. — In this variety there is a large 
amount of serous exudate as well as fibrinous. It may follow 
the fibrinous form, but usually begins with a serous out- 
pouring. The fluid is denser than that in hydrothorax, and 
contains bits of fibrin as well as red and white blood- cells in 
small numbers. The amount of fluid may be very little or 
as high as several liters. The exudate may become some- 
what hemorrhagic if large numbers of erythrocytes are pres- 
ent. The lung is pushed backward and the neighboring 
organs pressed upon. 

Hemorrhagic pleuritis is generally the result of tuber- 
culosis or of mahgnant disease of the pleura. The exudate 
is chiefly serous, with red blood-cells present, but at times may 
be almost pure blood. 

Empyema or purulent pleuritis is the result of infection by 
some one of many micro-organisms. It may begin as a 
purulent pleurisy or it may follow infection of a sero-fibrinous 
pleuritis. It may result from some traumatism causing an 
opening into the pleural sac or occur in the course of disease 
of the lung. In the adult its cause is most frequently the 
streptococcus, in children the pncumococcus. Tubercular 
infection in adults is nearly twice as frequent as in children. 
The infecting organism, whatever it is, can be carried to the 
pleura either by means of the lymphatics or the blood-vessels. 
The organisms most commonly found are the streptococcus, 
pncumococcus, tubercle bacillus, staphylococcus. 

In the pleural cavity there is found a small or a large 
amount of a cloudy purulent fluid which contains great num- 
bers of pus-cells. The color may be at times greenish, 
although usually yellowish. The plcurcT are generally thick- 
ened and congested and covered with flakes of fibrin and 
degenerated endothelium. The pus may be completely 
absorbed and the two inflamed pleurae unite with dense 
adhesions, or it may become cheesy and undergo calcareous 
infiltration. The changes are most marked in the visceral 



312 A MANUAL OF PATHOLOGY 

pleura, which becomes greatly thickened and at first is soft 
and edematous, while fluid is still present. When the exu- 
date disappears it becomes very hard and callous. 

During the course of the empyema there is always more or 
less involvement of the lung. The fluid by its presence tends 
to push the lung backward and compress it. This may con- 
tinue till expansion is impossible and atelectasis occurs. 
There may be an infection with resulting pleurogenic pneu- 
monia. Rupture of the empyema into the lung sometimes 
happens, in which case the result is generally fatal. 

Tuberculosis of the pleura is rare as a primary lesion ; is 
usually secondary to similar disease of the lung or adjacent 
tissues. The primary form occurs as small, round, pearly 
bodies about the size of a pea. The pleura may be in- 
volved in the course of a general hematogenic infection. Will 
vary greatly in appearance; many small miHary tubercles in 
some cases, while in others the pleura may be covered by a 
widespread exudate. The fluid present may be sero-fibrin- 
ous, purulent, or hemorrhagic. It may become inspissated 
and calcification take place. 

Syphilis of the pleura may be present as a part of a general 
syphilitic infection, but it is unimportant clinically and dif- 
ficult to recognize at any time. 

Tumors of the pleura are not very common, the most 
frequent variety being the endothelioma. It may be present as 
a diffuse infiltration of the pleura, resembling somewhat 
old adhesions, or in nodules scattered about. Secondary 
growths, as sarcoma or carcinoma, may result by metastasis or 
by direct extension from malignant disease of adjacent tissue, 
particularly by extension of carcinoma of the mammary 
gland through the chest wall. Other varieties found are the 
fibroma, lipoma, osteoma, and chondroma. 

Parasites. — Echinococcus cysts are occasionally found. 



CHAPTER XXI 
DISEASES OF THE DIGESTIVE SYSTEM 

Malformations. — ^The most common deformities are 
clejt palate and hare-lip. The former results from a failure 
of closure of the hard palate and is usually to one side of the 
mid-line. Hare-lip is the result of failure of union between 
the superior and premaxillary bones. May be single or 
double. The tongue may be either unusually large or small. 
Lack of development of the symphyses of the lower jaw 
sometimes occurs. 

The lips may be the seat of ulcers and fissures and some- 
times of a chronic inflammation with thickening. 

Anemia of the mucous membranes of the mouth and lips is 
commonly seen in cases of general anemia and is a well 
recognized symptom. 

Active hyperemia is found in inflammations and as an early 
symptom in certain infectious diseases. Passive hyperemia 
occurs in the general congestion of chronic lung and heart 
disease. Actual bleeding is found in scurvy and purpura and 
sometimes in the infectious fevers. 

Stomatitis. — Inflammation of the mouth results from 
many causes, but particularly from local infection by bacteria. 
It differs greatly in severity and is divided into catarrhal, 
ulcerative, mycotic, and gangrenous forms. 

Catarrhal Stomatitis. — This, the commonest form, results 
from the action of irritants, such as hot liquids, chemicals, 
decaying teeth, or from a depressed condition of the general 
system. There is marked hyperemia with desquamation of 
the epithehum. In chronic cases there is frequently a thick- 
ening of the mucous membrane with the formation of whitish 
areas. The mucous glands may enlarge and form small 

313 



314 A MANUAL OF PATHOLOGY 

cysts. Associated with the stomatitis there is an increased 
activity of the sahvary glands. 

Ulcerative stomatitis is usually found in children who are 
not well nourished. Occurs in malnutrition, tuberculosis, and 
in other chronic conditions, also in mineral poisonings, 
particularly by mercury and phosphorus. Is met with most 
commonly on the gums, although other parts may be involved. 
The gums become red and swollen and even hemorrhagic at 
the junction with the teeth. They become changed into a 
soft, necrotic mass that bleeds readily. The epitheHum is 
destroyed and deep ulcers form; suppuration may ensue and 
the teeth become so loosened that they fall out. The in- 
flammatory process may extend to the cheek and the tongue. 
There is marked increase of saliva, which has a bad odor. 
Mercury in small doses may cause it in some people who are 
especially susceptible; is then known as salivation. 

Mycotic stomatitis is that which is directly due to micro- 
organismal infection. Of this variety aphthous or jollicular 
stomatitis is an example. It occurs usually in children who 
are in poor physical condition. On the mucous membranes 
of the mouth there appear small whitish spots surrounded by 
an inflammatory zone. These areas consist of degenerated 
epithehum and fibrin, and the condition is therefore some- 
times spoken of as croupous stomatitis. Ulceration seldom 
occurs. The condition may last for some time, the exudate 
finally being absorbed and the epithelium regenerating. 

Thrush is that variety of mycotic stomatitis caused by the 
o'idium albicans which involves those structures covered by 
squamous epithelium. The tongue is most frequently involved 
primarily, but secondary infections through contact may 
develop. Usually occurs in marasmatic infants, but some- 
times in debilitated adults. There is at first a diffuse redden- 
ing of the mucous membrane, then the formation of patches 
of a shining, whitish false membrane that adhere at first 
rather tightly to the underlying tissue, but finally become 
loose. The patches may coalesce, forming large areas of 
a pseudo-membrane that is composed of desquamated 
epitheHum and parasitic threads. If the membrane is re- 



DISEASES OF THE DIGESTIVE SYSTEM 315 

moved it soon reappears. The disease may spread from the 
tongue to the pharynx and esophagus, and it has been known 
to extend into the stomach and bronchi. 

The oidium albicans is a budding fungus rcsembhng the 
yeast and forms long myceliae. Can be cultivated upon acid 
media that contain sugar. Longer threads form when grown 
on an alkahne medium. 

Gangrenous stomatitis or noma is a rapid necrotic process 
involving the mucous membrane of the cheek. It occurs in 
children whose general condition is extremely poor, either as 
the result of chronic or severe acute disease. At the angle of 
the lip on the buccal surface there appears a livid area that 
rapidly becomes gangrenous. Penetration through to the 
skin may occur or the process may remain localized in the 
mucous membrane. When the skin is involved there are 
vesicles formed and the tissue soon breaks down into a foul- 
smelling mass. Death from exhaustion and secondary 
infection usually follows. The slough may separate and the 
patient recover, with usually marked deformity from the 
cicatrization. Although more common in female children, 
noma may occur in either sex and at any age. This process 
has been met with in the genital regions. 

Syphilitic stomatitis may occur cither as the primary 
chancre or, what is more common, as the secondary mucous 
patch. The primary form may appear on the lip, tongue, or 
tonsil in either a soft or an indurated form. Is accompanied 
by enlargement of the lymph-nodes. The mucous patches 
are superficial ulcers following cellular infiltration. Other 
secondary lesions may be present. Gumma are also found 
either in the corners of the mouth or on the palate. Are 
generally small and prone to undergo softening with ulceration 
and subsequent cicatrization. 

Tuberculosis may rarely be primary, but is usually secondary 
to infection from tuberculosis of the larynx or pharynx or by in- 
fected sputum. Usually involves the posterior portion of the 
tongue, where small nodular tubercles of a yellowish- red color 
appear. They soon degenerate and form ulcers with thickened 
edges. The lesions may very closely resemble epithehoma. 



3l6 A MANUAL OF PATHOLOGY 

Actinomycosis may result from the infection of an abraded 
surface by the fungus. It generally gains entrance to the 
alveolar border of the jaw by way of carious teeth. The pro- 
cess is generally a slow one of swelHng with destruction of the 
adjoining tissues. There may be quite widespread involve- 
ment of the lymphatic nodes of the neck and jaw. 

Glossitis or inflammation of the tongue occurs either 
in a superficial or a deep form. In the superficial variety 
there is a desquamation of the epithehum. It may follow 
marked intestinal disorders or be the result of local irritations. 
The surface of the tongue becomes white or brown, due to the 
degenerated epithehum, particles of food, and bacteria. May 
become dry, hard, and fissured. If the superficial glossitis 
becomes chronic, local thickenings of the mucous membrane 
are formed. They arc irregular, slightly elevated, whitish 
patches, which may spread and coalesce. Occasionally the 
thickened epithehum may desquamate and leave an ulcer. 
This variety is known as leukoplakia or psoriasis linguce. 
Quite frequently secondary epitheliomata develop at the site 
of the lesion. 

The deeper inflammations of the tongue generally result 
from injury and infection. The organ may become swollen, 
painful, and infiltrated by leukocytes; small abscesses may 
also form. Is usually some degeneration and atrophy of the 
muscles. 

One form of inflammation of the tongue is known as melano- 
glossia, black tongue. The epithehum upon the papillae, 
particularly the filiform variety, becomes greatly increased 
and gives rise to a hairy appearance. The color may be due 
to an increase of pigment in the epithelium or to a fungus 
mixed with which are particles of food and bacteria. 

Tumors of all kinds are found within the mouth. Of the 
connective-tissue forms, lipoma, fibroma, myxoma, and sar- 
coma occur, also lymphangioma and hemangioma. Adenoma 
and carcinoma of the squamous type are found. Sarcoma 
generally appears upon the gums near the roots of the teeth 
and is known as epulis; is generally of the giant cell variety. 
Some epuh may be pure fibromata. The carcinoma is gener- 



DISEASES OF THE DIGESTIVE SYSTEM 317 

ally present in the form of the squamous epithelioma. Is 
found most commonly on the tongue at one side, where its 
course is quite rapid. It appears as a circumscribed hard 
swelling which soon breaks down and rapidly ulcerates. 
It soon involves the neighboring cheek and larynx, and gives 
metastases to the cervical and submaxillary lymph-nodes, and 
if excised it soon returns. 

Cysts result from obstruction to the ducts of the mucous 
or salivary glands. A ranula is a cystic dilatation of Nuhn's 
glands situated under the tip of the tongue, which may be 
displaced backward and upward. A thick viscid fluid fills 
the cavity. Dermoid cysts are also found. 

Macroglossia, thickening of the tongue, and macrocheiiia, 
thickening of the Hps, result from a lymphangioma. The 
lymphatic spaces are much distended and contain hquid and 
round cells. This condition is generally congenital; is met 
with in cretins. 

THE TEETH 

Malformations. — They may be unusually large or small, 
increased or decreased in number, or even entirely absent. 
In congenital syphihs the upper central incisors of the 
permanent set are frequently malformed, being deeply 
notched at the edge. 

Inflammation may involve the surrounding alveolar 
periosteum or the pulp of the tooth. It may go on to pus 
formation with loosening and death of the teeth. Caries is 
generally the result of malnutrition or lack of care of the teeth. 
The enamel of the tooth is destroyed by lactic acid, which is 
formed by many varieties of bacteria. The organisms are 
then able to enter the canals in the dentin with subsequent 
disintegration. The tumors of the teeth have been described 
in Part I. 

THE TONSILS AND PHARYNX 

Anemia and hyperemia occur here just as elsewhere. 
Active hyperemia as a beginning of inflammation; passive, 
in chronic heart and lung disease, in which cases the veins may 



3l8 A MANUAL OF PATHOLOGY 

be distinctly varicose. Edema is found in connection with in- 
flammation and ulceration and may be quite marked. Hemor- 
rhage may occur in purpura and in severe infectious fevers, 
as well as being the result of direct injury. The blood 
may form quite a tumor between the layers of the soft palate. 

Tonsillitis, or inflammation of the tonsil, may be either 
acute or chronic. Acute tonsillitis may be either symptomatic 
of various diseases or it may be a true local primary condition 
as a consequence of direct infection. It is known as ca- 
tarrhal, lacunar or jollicular, and phlegmonous. In the 
catarrhal the tonsils are somewhat reddened, usually as a 
part of a catarrhal pharyngitis. The lacunar or folhcular 
form is characterized by the presence of many small yellowish- 
white spots over the surface of the tonsil. Each spot rep- 
resents a folhcle that has become filled with an exudate made 
up of degenerated epithehum, and bacteria, as staphylococci, 
streptococci, pneumococci, and tubercle bacilh. The exu- 
date from the lacunae may extend over the surface of the ton- 
sil, forming a covering that resembles diphtheritic pseudo- 
membrane. The exudate within the lacuna? may become 
inspissated and calcify. If the infection passes through the 
bottom of the crypts into the deeper tissues phlegmonous 
tonsillitis may result. In this there is abscess formation as 
well as round-cell infiltration. These collections of pus may 
discharge into the mouth, open into the larynx or even in- 
volve the large vessels of the neck, perforation of the internal 
carotid having occurred. 

In chronic hypertrophic tonsillitis there is an increase in size 
of the tonsils, due not only to a hyperplasia of the connective- 
tissue septa and reticulum, but also to a hyperplasia of the 
lymphoid follicles. The tonsils may become so hypertrophic 
as to almost meet in the middle fine, and by so doing cause 
obstruction to breathing and swallowing. 

This form is frequently accompanied by marked distur- 
bance of the general health and development. Is often found 
in children, and as a result they breathe with their mouths 
open; their digestion is often impaired and their mentality 
may be distinctly lessened. 



DISEASES OF THE DIGESTIVE SYSTEM 319 

Instead of the above hypertrophic form, the involvement 
may be confined to the lacunae, which are wider and deeper 
than normal. They become filled with an exudate that 
through decomposition can give rise to inflammatory pro- 
cesses in adjacent tissues. 

Tonsillitis leptothricia is caused by infection of the tonsils 
by the Leptothrix buccahs. It usually occurs in the poorly 
nourished, but may occur in a strong, well-nourished indi- 
vidual. Over the surface of the tonsil are numerous spots 
covered by a thick, dense, dry, whitish exudate that is com- 
posed of masses of threads of the leptothrix. It is firmly ad- 
herent to the crypts and is removed with difficulty. It 
usually involves other portions of the pharynx, but does not 
occasion much inflammation of the surrounding tissues. It 
tends to run a chronic course not yielding readily to treat- 
ment. 

Tuberculosis of the tonsils is quite common. Is generally 
primary and involves the cervical lymph-nodes secondarily. 
From there it may by extension gain access to the lungs and 
occasion tuberculosis within them. It may also give rise to 
a secondary involvement of the intestines. 

Syphilis of the tonsils may occur as a primary, secondary, 
or tertiary lesion. 

PHARYNX 

Circulatory disturbances are usually a part of similar 
troubles of neighboring tissues. 

Inflammation. — ^Thc acute catarrhal pharyngitis or 
angina may result from exposure to cold, to the irritating 
action of various substances, as tobacco smoke and dust, or 
may occur as a part of an intestinal derangement. The mu- 
cous membranes become red and swollen with decreased 
secretion at first. As the process goes on there is frequently 
an abundance of a thick, tenacious secretion composed of 
mucus and desquamated columnar cpithehal cells. In 
severe cases true ulcers may form along the posterior wall. 

In chronic pharyngitis^ such as occurs in excessive smokers 
and in those who use their voice a great deal, the posterior 



320 A MANUAL OF PATHOLOGY 

wall and the faucial pillars are particularly involved. There 
is chronic congestion and the lymphoid collections become 
hyperplastic, causing slight granular elevations. The secre- 
tions become less, as a rule, but may be increased and muco- 
purulent. The pharyngeal tonsils are usually hyperplastic. 

Phlegmonous pharyngitis and retropharyngeal abscess 
follow the entrance of bacteria, usually pyogenic, into the 
deeper tissues or may result from caries of the spinal column. 
If there is rapid abscess formation there is bulging into the 
pharynx and rupture may take place. If the process has been 
slower the pus will extend along the deep fascia till perforation 
into the posterior mediastinum, bronchi, or esophagus occurs. 
General septicemia not infrequently occurs. 

Syphilitic pharyngitis is common as a secondary symptom, 
but it has no characteristic appearance that renders it easily 
recognizable. 

Tubercular pharyngitis is unusual. 

Pseudomembranous pharyngitis may be diphtheritic or non- 
diphtheritic. 

The non-diphtheritic pharyngitis is generally caused by the 
streptococcus pyogenes or may result from the action of very 
irritating substances, as steam or ammonia. The appearance 
of the pseudo-membrane is, to the naked eye, similar to that of 
the diphtheritic variety. It is not, however, accompanied by 
the same constitutional depression, nor is it followed by 
paralyses. 

Diphtheritic pharyngitis is caused by the Klebs-Loeffler 
bacillus and characterized by a pseudo-membrane that is 
yellowish or dirty gray in color. The involvement may be 
limited to a small portion of the pharynx, being most common 
on the arches of the fauces, or the tonsils and nares as well 
may be concerned. It may extend even into the esophagus 
and stomach. This pseudo-membrane is laminated, being 
composed of fibrin in the meshes of which are desquamated 
epithelial cells, leukocytes and er\lhrocytes, and the diph- 
theria bacilH in great numbers. It is formed by the coagula- 
tion of the exudate and by coagulation necrosis of the super- 
ficial tissues. 



DISEASES OF THE DIGESTIVE SYSTEM 



321 



This membrane can be removed, exposing a raw ulcerated 
surface upon which a new membrane quickly forms. The 
lymph-nodes near-by may enlarge and undergo suppuration. 



"4f -;•;■■;■'. _ , ; 




i W'.'-l-'^-r-: 


'•''•'• '■ ' '.', ■"; '•'..•'. '.'•; .' • • < v..'/.-','" 










:."h 



'::,ti"'- 










^:i^?^-^ 



Fig. 131. — Diphtheric Membrane from the Uvula. X 50 (Ziegler). 
a, h, c, Layers of fibrin containing epithelial cells, leukocytes, and 
bacteria; d, e, cellular infiltration of the connective tissue; /, collections of 
red corpuscles; g, dilated blood-vessels. 



The extent of the pseudo-membrane does not denote the 
gravity of the infection. The severity depends upon the viru- 
lence of the particular bacillus that has caused the infection; 
it is the expression of the intensity of the toxin present. In 



322 A MANUAL OF PATHOLOGY 

severe forms it spreads rapidly, and if there is a mixed infection 
with streptococci, hemorrhage and gangrene may result, as 
well as secondary abscess formation elsewhere in the body. 
Besides the local manifestations there are marked general 
symptoms due to the presence of a dangerous toxin. The 
action of this body is seen in the form of small foci of necrosis 
in \arious tissues of the body. Death may result from cardiac 
paralysis resuhing from the })resence of the toxin. 

Of the internal organs the liver especially shows focal 
necrosis, in which the cells are degenerated and the nuclei show 
hyperchromatosis. There is hyperemia of the kidney with 
cloudy swelling of the epithelium, edema, and hemorrhage. 
Myocarditis and degeneration of the cardiac muscle also 
occur. The spleen is also hyperemic. 

During convalescence paralysis, particularly of the throat, 
may occur, also of the muscles of the eyes, the larynx, and the 
diaphragm. The muscles will show a round-cell infiltration 
between the fibers and a granular and fatty change of the 
cells. 

There may be degeneration of the ganglion cells of the cord. 

Tumors of the pharynx are rare. Squamous epithelioma 
as a result of extension is the most common, but fibromata 
and sarcomata have been encountered. 

SALIVARY GLANDS 

Inflammation of the parotid gland, parotitis, or mumps, 
occurs as an independent disease, possibly due to a small 
diplococcus described by Laveran. The infection probably 
occurs by way of the parotid duct; the gland becomes much 
swollen and tense on account of a marked serous exudation. 
Although abscess formation appears imminent, it is very un- 
usual for suppuration to occur. The exudate can be ab- 
sorbed and the gland return to a normal condition very 
rapidly. There may be a chronic induration remaining, or 
if abscess formation with rupture has taken place, a fistula may 
result. Secondary infiammation of the testicles or of the 
ovaries may occur either during the attack or shortly after 
the inflammation has subsided. 



DISEASES OF THE DIGESTIVE SYSTEM 323 

In the inflammation secondary to infectious diseases, as 
typhoid, scarlet fever, diphtheria, and others, suppuration is 
not so uncommon. Small abscesses may form and become 
confluent. The inflammation may become chronic with 
hyperplasia of the fibrous connective tissue, or it may subside 
and leave no traces. 

Angina ludovici is a very severe form of inflammation of 
the submaxillary gland. The infection extends into the 
surrounding tissues, with suppuration and even gangrene. 
Abscesses form and discharge either externally or in the 
mouth; necrosis and gangrene are present and death fre- 
quently occurs. This disease may be the result of infection 
by means of carious teeth or infection of the gland itself during 
the course of an infectious disease, particularly scarlet fever. 

Fistulae of the salivary ducts may follow traumatism or 
the perforation of an abscess. The parotid duct is the one 
generally involved. 

Concretions or calculi are sometimes found; are called 
sialoliths. They are composed of phosphate and carbonate 
of calcium, and are found in the smaller as well as the main 
duct. They frequently give rise to retention cysts, the most 
common variety being that known as ramila, a term applied 
not only to a cystic condition of Nuhn's glands but of the 
sublingual as well. 

Tumors of the salivary glands are not uncommon, the 
parotid being most frequently involved, the connective-tissue 
tumors, as fibroma, lipoma, chondroma, and sarcoma, being 
the most usual. Adenoma and primary carcinoma are un- 
usual. The most common neoplasm is the mixed tumor of 
the parotid. This is composed of sarcomatous tissue, along 
with cartilage, mucous and fibrous tissue. It grows slowly, 
does not frequently give metastasis, and when excised seldom 
returns. It is probably the result of fetal inclusions taking 
place during the closure of the first branchial cleft. 

THE ESOPHAGUS 

Malformations. — It may terminate in a blind pouch in 
its upper portion ; it may be double or completely wanting. 



324 A MANUAL OF PATHOLOGY 

Fistulae opening into the pharynx and neck are the result 
of incomplete closure of the branchial arches. 

Circulatory disturbances may be part of a general con- 
dition. In diseases of the heart, lungs, and in cirrhosis of 
the liver passive congestion with varicose veins may be 
present. 

Inflammation of the esophagus, csopJiagiiis, may be 
the result of irritation of foreign bodies, as hot hquids, acids, 
and alkalies, or of infection. In the catarrhal type there is 
hyperemia, infiltration of the mucous coat, and desquamation 
of epithelium, with occasional ulcer formation. If the pro- 
cess becomes chronic, as in long- continued passive con- 
gestion and in alcoholics, the mucous membrane is thickened, 
and thrown into folds; is dark in color, ulcers are present, and 
there may be hypertrophy of the muscular coat. 

Pseudo-memhranoiis esophagitis may be the result of in- 
fection by the streptococcus or by the diphtheria bacillus; 
is usually secondary to extension from neighboring tissues 
that were primarily involved. 

Suppurative esophagitis may result from the extension of 
inflammation from the mucosa to the submucous coat, or it 
may be due to traumatism involving the deeper tissues. 

In smallpox ulcers may form as a result of the eruption of 
pustules and thrush may extend from the mouth. 

Stenosis of the esophagus may be the result of interference 
from within or from without. Compression by tumors, 
aneurv'sms, or other lesions. Strictures may be very marked. 
They usually result from the contraction of cicatrices formed 
in the healing of ulcers due to the swallowing of destructive 
Hquids, as acids and alkalies. May be caused by syphihs, a 
rare occurrence. Carcinoma may cause stenosis by pro- 
jecting into the lumen or by contracting the walls. 

Dilatation of the esophagus is the result of an obstruction 
and usually occurs at the cardiac end, where it passes 
through the diaphragm into the stomach. Sometimes dila- 
tation occurs without stenosis, in which case the esophagus is 
in the form of a pouch, largest at its center. 

Diverticula or local sacculations of the esophageal wall 



DISEASES OF THE DIGESTIVE SYSTEM 325 

may be due to pressure from within, pulsion diverticula, or to 
traction from without, traction diverticula. 

The pulsion diverticula are more common at the upper part 
of the tube, where the greatest pressure occurs. There is 
loss of tone of the muscular coat and the mucous membrane 
projects in the form of a pouch from the posterior wall at the 
pharyngeal junction. They may be very small or as large as 
a pear. They communicate with the lumen of the esophagus 
and become filled with food which is retained. This fre- 
quently undergoes decomposition and sets up inflammatory 
changes in the mucosa and adjacent tissues. 

Traction diverticula are more common and are found near 
the lower end of the esophagus at the bifurcation of the 
trachea. They are the result of the contraction of adhesions 
of diseased bronchial glands. Are generally on the anterior 
wall and are conical in shape with the apex directed outward 
at the seat of the adhesion. There may be no change in the 
constituents of the wall, or the muscular coat may be lacking. 
Perforation may occur if the tension at the apex becomes too 
great. Escape of the contents may take place into the pleura, 
pericardium, or lungs. Death may result from hemorrhage 
following perforation of a pulmonary artery. 

Pcrjoration of the esophagus may depend upon causes 
acting either from within or from without. It may follow 
from ulcerations caused by the pressure of the cricoid cartilage 
in bed-ridden patients, or from syphilitic or cancerous ulcers. 
It may be due to outside pressure from caseating glands, 
abscesses, gummata, or aneurysms of the aorta. Rupture 
may be the result of traumatism or be spontaneous. In- 
flammation to the grade of gangrene may follow the escape 
of material from the perforated esophagus. If the gastric 
contents regurgitate there may be a partial digestion of the 
walls of the esophagus. This may, however, be a post-mor- 
tem condition. 

Tumors are not very common, aUhough of the connective- 
tissue tumors the fibroma, myxoma, myoma, fipoma, and 
more rarely sarcoma have been observed. The most com- 
mon growth is the squamous epithelioma. It is most fre- 



326 A MANUAL OF PATHOLOGY 

quently found in the lower third at the place where the left 
bronchus crosses over. The growth is flat, more or less 
ring-Hke, and usually ulcerated. The mucous coat is de- 
stroyed and papillary projections extend into the esophagus 
and cause obstruction of the lumen. The submucosa and 
the muscular coat may become infiltrated and the adjacent 
tissues also involved. There is stenosis with subsequent 
dilatation above the tumor. Food is retained and ulceration 
with perforation may occur. ^letastatic growths are found in 
the neighboring lymph-nodes, bronchi, pleura, lungs, and hver. 

THE STOMACH 

Malformation. — It may be completely absent, or ab- 
normally small, with atresia or stenosis of the pylorus, or it 
may be in the form of two pouches connected by a smaller 
tube (hour-glass stomach). The stomach may be reversed 
in its position in transposition of the viscera. 

Circulatory Disturbances. — Anemia occurs in cases of 
general anemia, accompanied, if long continued, by fatty 
degeneration and atrophy of the mucous membrane. The 
mucosa is thin and frequently smooth. Active hyperemia 
is present normally during digestion, and is widespread. 
If the result of irritation, the color is more intense and is dis- 
tributed in irregular streaks or patches, particularly on the 
tops of the rugce. Passive hyperemia is the result of venous 
stasis in chronic heart and lung diseases and cirrhosis of the 
liver. The mucosa is purplish in color, swollen, and edema- 
tous. Small punctate hemorrhages may occur and also 
small erosions. The changes are most marked near the 
pyloric end. 

Hemorrhage of varying severity frequently occurs. The 
punctate form, that is found so repeatedly at post-mortems, 
is in many cases the result of vomiting during the last mo- 
ments of life. It may also result from congestion and in- 
flammation, or be met with in various infectious and hemor- 
rhagic diseases. If examined carefully, it can generally be 
seen that over these hemorrhagic points there is a loss of 
epithehum. The mucosa not being properly nourished at 



DISEASES OF THE DIGESTIVE SYSTEM 327 

that point is unable to withstand the action of the gastric 
juice. 

Massive hemorrhage occurs in destruction of the mucosa 
in the course of gastric ulcer and gastric carcinoma. In the 
peptic ulcer the bleeding usually comes from the erosion of a 
single blood-vessel and may be so great as to cause death. 
In the carcinoma there is a slow oozing from degenerated 
capillaries, with the "coffee-grounds vomit," blood that has 
been acted upon by the gastric juices. Melcena neonatorum, 
vomiting of blood by new-born infants, is accompanied by 
the formation of ulcers of the gastric mucosa. It apparently 
results from imperfect respiration, causing a backing up of 
the blood. By many it is thought to be due to some cerebral 
lesion. 

Thrombosis of the gastric vessels is rare, but is thought by 
many to be a cause of peptic ulcer and also of the ulcers that 
are found in the stomach and duodenum in cases of extensive 
burns. Embolism is more common; occurs in the course 
of cardiac disease. 

Inflammation or Gastritis. — The acute form is generally 
due to the irritation of certain substances taken into the stom- 
ach and is commonly found at the pyloric end. The mucosa 
is red, thickened, and covered by mucous secretion, and punc- 
tate hemorrhages arc occasionally present. Microscopically 
the epithelial cells are found to be the seat of cloudy swelling, 
numerous goblet cells are present, and there is an infiltration 
of round cells. The lymph follicles are also frequently 
hyperplastic. 

Pseudo-membranous gastritis may be due to the action of 
caustic substances or to some of the infectious fevers, as 
smallpox and scarlatina.. It may also be the result of the 
extension of a true diphtheritic process. The mucosa is 
covered by patches of a grayish-white pseudo-membrane 
under which the necrotic process may have involved the entire 
mucosa. 

Phlegmonous gastritis is very rare, but sometimes follows 
the entrance of streptococci. The submucosa and muscu- 
laris become swollen and infiltrated by pus cells even to the 



328. A MANUAL OF PATHOLOGY 

extent of more or less circumscribed abscesses. These may 
finally rupture into the cavity of the stomach. Healing 
takes place by the extension of the epithelium from the neigh- 
boring tissues into the opening resulting from the rupture of 
the abscess. 






'"i-'f ,-,>. 









My::,^,,- ■ 



MKp^'''" 




:^ 


m^^^ 






/S^;|S/A^'^ 


> 


-> 



# 
^ 



Fig. 132. — Chronic Gastritis (McFarland). 
The mucosa is infiltrated with leukocytes, the glandular tissue -has in 
part disappeared, and some of the glands (a) have developed into cysts; b, 
mucosa; c, submucosa. 



Chronic gastriti^s may be the result of repeated acute 
attacks or it may have been chronic in form from the onset. 
It follows the abuse of alcohol, results from the eating of 
improper food, and occurs also in the course of various con- 



DISEASES OF THE DIGESTIVE SYSTEM 329 

stitutional diseases. Chronic congestion predisposes. In 
the simple chronic variety the mucosa is thickened, hyper- 
plastic, and infiltrated, and bands of connective tissue sur- 
round projecting areas of epithehum. This is most marked 
at the pyloric end, where the mucosa may be markedly 
wrinkled and is associated with polypoid projections. 
Sclerotic or interstitial gastritis probably is due to the long- 
continued action of a mild irritant. There is an increase of 
the connective tissue, which as it contracts causes atrophy of 
the glands. The mucosa is very much thinner than normal, 
grayish in color, and in places there are frequently seen 
large but sHght ulcerations. From the contraction of the 
new-formed connective tissue stenosis of the pylorus some- 
times occurs. 

Peptic or round ulcer is a peculiar form of ulceration 
generally found in the posterior wall in the lesser curvature at 
the pyloric end of the stomach, and probably due to the action 
of the gastric juice. It is thought to be due to a thrombosis in 
a vessel giving rise to a local area of necrosis, which being no 
longer able to resist the action of the gastric juices undergoes 
digestion. Infection, embohsm, infarction, spasmodic con- 
tractions of the blood-vessels, are all thought to have some 
bearing upon the formation of these ulcers. They are found 
most frequently in chlorotic girls in whom there is an asso- 
ciated increase in the acidity of the gastric juice. The peptic 
ulcer is usually single and small, but is sometimes multiple 
and large. It is generally round or slightly oval, wider at the 
top than at the bottom, and is accompanied by ver}^ Httle 
inflammation. The mucous layer alone may be involved, 
or the destruction may extend to the submucosa, the muscu- 
laris, or even to the serous covering. In healing there is 
cicatricial tissue formed which on contracting gives rise to a 
peculiar white stellate scar. If the ulcer was in the region of 
the pylorus, stenosis of that outlet may result. From the 
tloor of the healed ulcer carcinoma sometimes develops. 
The two dangerous resuhs are perforation or hemorrhage. 
The perforation is usually smooth and round and looks as if 
it had been punched out. Sometimes there have been ad- 



330 A MANUAL OF PATHOLOGY 

hesions to neighboring organs, so that damage is prevented, 
but more frequently the gastric contents will escape into the 
abdominal cavity and give rise to peritonitis. Hemorrhage 
is the result of ulceration of a large arterial branch. This 
is more common than perforation. The amount of blood 
lost may cause death or there may be merely a constant oozing. 

Peptic ulcers sometimes occur in. the upper end of the duo- 
denum close to the pyloric orifice and also in the lower portion 
of the esophagus. 

Atrophy of the glands results from chronic inflammation 
and is also found in old age and in cases of pernicious anemia. 

Fatty metamorphosis of the glandular epithehum may 
follow phosphorous poisoning or occur in the course of severe 
infectious diseases. The mucous membrane is duller and 
more yellowish than usual. 

Amyloid change is present chiefly in the muscularis, but 
also to a slight extent in the mucosa. It generally first ap- 
pears in the walls of the smaller arteries of the submucosa. 

Pigmentation of the mucosa is the result of numerous 
small hemorrhages or occurs as a part of a general discolora- 
tion often seen in chronic malaria. The mucosa is of a dark, 
slaty discoloration. 

Calcification of the stomach in small areas has sometimes 
been found in certain poisonings, such asbichlorid of mercury, 
that are accompanied by rapid absorption of lime sahs from 
the bones. Particles of calcium carbonate are found in the 
interstitial tissue. 

Gastromalacia is a condition of softening of the stomach 
walls due to post-mortem changes resulting from the action 
of the gastric juices. Is most marked w^hen there is hyper- 
acidity and in that part of the stomach that has been most 
dependent. If the organ was anemic the mucous membrane 
appears pale gray in color and somewhat gelatinous in con- 
sistency. If congestion was present the mucosa will be dark 
brown. This is particularly marked along the veins, the 
hemoglobin being transformed into hematin. Sometimes 
perforation may occur, but this can be recognized readily, as 
there will be no local inflammatory reaction or peritonitis. 



DISEASES OF THE DIGESTIVE SYSTEM 33 1 

Gastroptosis is a downward displacement of the organ 
either acquired or congenital, and is very frequently a part of 
a general displacing or splanchnoptosis of all the abdominal 
viscera. 

Dilatation or gastrectasis is usually due to some ob- 
struction at the pyloric outlet. Food is retained; this under- 
goes fermentation and the stomach walls become weaker than 
ever. This may continue until the organ becomes enormously 
distended, the mucosa becoming very thin and atrophic. 
The stomach may be so greatly dilated that the greater cur- 
vature will extend not only below the umbilicus, but even 
down into the pelvis. There may be also a displacement in 
position, the organ lying almost perpendicularly. Dilata- 
tion may also be due to the contraction of adhesions to the 
outer surface of the stomach. 

In some cases, the atonic form, there is a weakening and a 
relaxation of the walls without any obstruction at the pylorus. 
In gastrectasis there may be most marked indications of 
malnutrition. 

Tuberculosis is extremely rare and syphilitic lesions but 
little more frequent, although gummata may be found. 
Sometimes a diffuse cirrhosis of all the gastric coats may be 
found in syphilitics. 

Anthrax, actinomycosis, and glanders have been de- 
scribed. 

Tumors. — ^The connective-tissue tumors, as fibroma, 
myoma, and lipoma, have been occasionally found. ^'<7;'- 
coma is more rare; it seems to originate within the lymphoid 
deposits and is generally round-cell in character. Polypoid 
projections of the mucous membrane are sometimes confused 
with tumors, but they are not neoplastic, are the result of 
chronic inflammations, and arc sometimes cystic. 

Adenomata have been found, but they are unusual, as they 
generally very quickly undergo a carcinomatous degenera- 
tion. 

Carcinoma is not uncommon and is nearly always primary. 
It is more frequent in men than in women, usually in middle 
or advanced hfe. Its most frequent scat is at the pyloric end 



332 



A MANUAL OF PATHOLOGY 



of the stomach, on the posterior wall of the lesser curvature. 
It sometimes first appears at the cardiac end. The walls 
may be more or less involved in the process. The appearance 
of the orrowth differs crreatlv accordinsr to its histolosfic char- 

o 0,0 o 

acteristics. 

Scirrhus cancer is usually situated at the pyloric opening, 
which may be completely or partially surrounded. The 
walls are thickened and indurated. The opening is much 
i^tenosed and the mucous surface may be smooth or irregular 




Fig. 133. — Scirrhus of the Pylorus, Causing Pyloric Stenosis (Orth). 
D, Duodenum; P, pylorus; K, carcinomatous projections on the mucosa. 



with depressed and ulcerated areas. Microscopically there 
will be seen large amounts of dense connective tissue with a 
few atypical epithelial cells. 

Medullary carcinoma generally appears at the pylorus, but 
sometimes on the wall in the lesser curvature. The growth 
is irregularly elevated, spongy, and cauhflower-like. Is soft 
and vascular and ulcerated, particularly in the center, thus 
forming a crater-like excavation where perforation may 
occur. Alicroscopically the epithelium predominates and 
retains to some extent the normal arrangement, although the 



DISEASES OF THE DIGESTIVE SYSTEM 333 

individual cells rapidly become more globular and less 
columnar. 

Malignant adenoma or adenocarcinoma begins as a prolif- 
eration of the glandular tubules. The cells retain to a great 
extent their usual shape and regular arrangement. Further 
away from the original focus the glandular conformation be- 
comes less and less marked, until it may completely disappear 
and be replaced by the usual carcinomatous picture. 

Colloid cancer may be localized or, what is more common, 
diffuse. The mucosa and submucosa may be markedly 
infiltrated and the surface covered by a gelatinous material. 
This is better seen deeper in the tissues, as that exposed is 
dissolved by the gastric juices. On section a yellowish 
gelatinous material escapes. The cells are cylindric and 
there is a myxomatous degeneration of them and of the inter- 
cellular elements. 

Squamous epithelioma occurs at the cardiac end of the 
stomach in connection with involvement of the esophagus. 
Is very rare. 

Results oj Cancer oj the SlomacJi. — The involvement gener- 
ally takes place within the gastric tubules. This is soon 
followed by an infiltration of the submucosa, the muscularis, 
and finally the serous covering, upon which there appear 
nodules. Perforation of the wall may then occur with sub- 
sequent involvement of the peritoneum; this is especially 
so in colloid cancer. Neighboring organs, as the liver, pan- 
creas, and colon, may be affected by contiguity. If ad- 
hesions have formed perforation may be prevented and the 
neighboring tissues protected. Fistulous tracts may be opened 
between the stomach and duodenum or transverse colon, 
or with the pleura. Metastases may take place first in the 
neighboring lymphatics and then in more distant tissue, or 
secondary nodules may follow the entrance of tumor cells 
into veins. These are commonly carried to the Hver, where 
they lodge and grow. The metastatic growths may be so 
large as to conceal the primary neoplasm. If at the pylorus 
there will be all the symptoms of obstruction, such as 
retention of food with decomposition. 



I 



334 A MANUAL OF PATHOLOGY 

Lactic acid fermentation is particularly common, as there 
is generally a lack of hydrochloric acid secretion. The stom- 
ach may become enormously dilated. 

Following the ulcerati\'e processes there may be extensive 
hemorrhage from the opening of a blood-vessel or there may 
be merely an oozing with the presence of the ''coffee grounds" 
vomit. 

Foreign bodies of many kinds may be found, either 
accidentally or intentionally swallowed. Intestinal parasites 
may also be present. 

DISEASES OF THE INTESTINES 

Malformations. — Complete absence may occur, but in- 
complete development is more common. There may be 
stenosis anywhere. The rectum may end in a blind sac, 
atresia ani, either low down or u]) in the sigmoid flexure. 
Cloaca formation refers to a condition in which there may be 
one common cavity acting as an outlet for the rectum and 
genito-urinary tracts. Diverticula, locaHzed dilatations, are 
quite frequent, particularly McckeVs diverticulum. This 
is found in the ileum about three feet above the ileocecal 
valve. It is a finger-like projection of the same histologic 
formation as the intestine; is the remains of the omphalo- 
mesenteric duct. It may be adherent at the umbilicus, re- 
main open, and allow feces to escape. Entcrocysts are dilata- 
tions of the omphalo-mesenteric duct. There may be a 
transposition of the intestines, the colon ascending on the left 
and descending on the right. There is frequently an ab- 
normal course of the large intestine, particularly of the trans- 
verse colon. This, instead of going directly across the upper 
part of the abdomen, takes a V-shaped course, the apex of the 
curve frequently extending as low as the pubes. 

Hernia of the intestines refers to the abnormal entrance into 
or the passage through an opening. 

Hernias may be due to a weakening of the abdominal walls 
or to the failure of a canal to close. The mesentery may be 
longer than usual and allow very free motion, or there may 
be an abnormal amount of fat, causing an increase of weight. 



DISEASES OF THE DIGESTIVE SYSTEM 335 

The exciting cause in most cases is sudden exertion, or it 
may be the result of repeated strains. 

Herniae may be external or internal, congenital or acquired. 

External are those in which the hernial sac lies outside of 
the abdomen. Internal are those in which the sac lies within 
one of the cavities within the body. 

Inguinal. 

Femoral. / Winslowian. 

UmbiHcal. \ Mesenteric. 
External (Obturator. Internal Omental. 

Ischiatic. I Diaphragmatic. 

Labial. \ Retroperitoneal. 
Perineal. 

The sac may contain only a portion of the small intestine 
or there may be some of the large abdominal organs present. 
There is generally a constriction (neck) at the point where the 
sac passes from the peritoneal cavity; below is a dilated pouch 
The inner wall of the sac is composed of the peritoneum. 

A hernia is reducible if it can be pushed back through the 
opening from which it escaped. If it cannot be returned it 
is an irreducible hernia. The reduction may be prevented by 
adhesions having formed at the neck of the sac, by the ac- 
cumulation of fecal matter, by edema or other causes. There 
may be such a constriction at the neck as to interfere with the 
circulation, a strangulated hernia. This may result from the 
same conditions, in a more severe degree, as cause an irredu- 
cible hernia, or from the entrance of more viscera into the sac. 
It is followed by an extreme passive congestion, inflammation 
of neighboring tissues, and hemorrhage and gangrene. If 
the strangulation is relieved early before degenerative changes 
have set in, the intestine may resume its usual condition. 

In old hernias a chronic inllammatory process may have 
gone on, with the formation of fibrous adhesions between the 
sac and neighboring coils of intestine. This is due to the 
circulatory disturbances resulting from the twisting or 
stretching of the vessels. 



7,7,6 A MANUAL OF PATHOLOGY 

Obstruction of the intestine may be due to the presence 
of foreign bodies within its lumen, to fibrous adhesions and 
bands, to a twisting or volvulus, to intussusception or in- 
vagination, or as a result from the formation of cicatrices at 
the seat of ulcerations. If the obstruction has been a chronic 
one, there will probably be some dilatation of the intestine 
above the constricted area. The part below may become 
atrophic. 

Volvulus is the twisting of the intestine resulting in ob- 
struction. It may twist in its long axis, but usually a loop of 
intestine twists around its mesenteric attachment. It occurs 
where the mesentery is unusually long and lax. The most 
common seat is in the sigmoid flexure. In volvulus there is 
a consequent obstruction to the blood-supply, and if the con- 
dition is not rapidly remedied, thrombosis, edema, and gan- 
grene ensue. Above the twist the intestine will be dilated, 
there will be passive congestion, and frequently ulceration 
with perforation. Sometimes adhesions may form with a 
neighboring loop of intestine and no peritonitis result. 

Intussusception or invagination is a condition in which 
one part of the intestine shps into the lumen of an adjoining 
part, Hke a glove-finger. The outer covering is called the 
intussiiscipiens or sheath; the inner portion, the intussus- 
ceptum. Is most frequent in young babies and most common 
near the ileocecal valve. It may be due to convulsive or to 
reverse peristalsis. In children there may be found at the 
post-mortem table numerous invaginations which probably 
occurred during the death agony and have no significance. 

The ensheathed portion may be very short or it may ex- 
tend many feet. As a result of the invagination peristalsis 
is increased and the tendency is for the intussusception to 
become greater and greater. As the intestine is invaginated 
the mesentery is taken with it and the circulation is interfered 
with. That is followed by congestion, edema, and inflamma- 
tion; a result of which is the formation of adhesions rendering 
the displacement permanent. If the process has been more 
acute, obstruction with gangrene and peritonitis usually 
follow. Sometimes the invaginated portion may slough off, 



DISEASES OF THE DIGESTIVE SYSTEM 337 

be passed through the rectum, and the edges of the intestine 
unite without any peritonitis resulting. There may be merely 
a stenosis through which fluid contents can pass. 

Occasionally the rectum may extrude from the anus — 
prolapse. It usually occurs as a result of strained defeca- 
tion. Is generally very easily reduced, but is hkely to recur, 
as the sphincter muscle is usually weak. If allowed to re- 
main, the prolapsed portion becomes inflamed, the mucous 
surface ulcerated, and necrosis may occur, as a result of acute 
strangulation by constriction of the sphincter. 

Stenosis or narrowing of the lumen sometimes occurs, 
usually as a result of the contraction of cicatrices formed 
after ulceration. The primary ulcer may be syphihtic, tu- 
bercular, or rarely typhoidal. 

The syphilitic ulcer has its long diameter at right angles to 
the long axis of the intestine and is generally completely annu- 
lar. It is characterized by extensive fibrous tissue formation 
which, subsequently contracting, causes stenosis. The tuber- 
cular form hes transverse to the intestine, but does not com- 
pletely encircle the gut. Constriction may occur as a result. 
The typhoid ulcer has its long axis parallel to that of the in- 
testine and docs not tend to form much fibrous tissue. If 
there is a cicatrix formed, there is usually merely a puckering 
of the intestine. 

Stenosis may result from the presence of a neoplasm 
within the intestine or from pressure from, without. 

Dilatation results from incomplete obstruction. Is most 
marked in the large intestine as a result of retained fecal 
matter which undergoes decomposition and assists in the 
dilatation. This condition is usually associated with local- 
ized pouches or diverticula. Are most common in the rectum. 

Perforation may be due to traumatism or may result from 
ulceration. If the opening is a small one, it may be filled up 
by a plug of fibrin and no damage result; if larger, there will 
be an escape of fecal contents into the peritoneum, with fatal 
results. If the process of ulceration has been a very slow one, 
as in tuberculosis, such dense adhesions may have formed as 
to prevent the escape of fecal contents into the abdominal 
22 



338 A MANUAL OF PATHOLOGY 

cavity. Instead of opening within the body the perforation 
may open out onto the skin surface, giving rise to a fecal 
fistula. 

Rupture may follow injuries of the abdomen or may result 
from accumulations of gas. 

Circulatory Disorders. — Acute congestion may result 
from active irritation or as the early stage of inflammation. 

Passive congestion is common in diseases of the liver asso- 
ciated with engorgement of the portal veins, and to a less 
degree in chronic heart and lung disturbances. Local con- 
gestion is the result of some limited in\olvcment of the mesen- 
teric veins. The veins are swollen and prominent, the mu- 
cosa is swollen, edematous, dark bluish in color, and small 
petechial hemorrhages may be present. 

Minute JiemorrJiagcs may occur in chronic passi\e con- 
gestion and in hemorrhagic diatheses. Severe hemorrhage 
may follow ulcerations of all kinds, particularly from the 
typhoidal, or wounds, such as the bites of intestinal parasites. 

Edema is present in chronic passive congestion, and in in- 
flammations, particularly if severe. 

Embolism and thrombosis may occur. As a rule, there 
are no bad results, as the anastomoses are so extensive that 
necrosis does not occur. It may, however, be followed by 
hemorrhagic injarction with fatal necrosis of the portion of 
the intestine involved. The formation of the duodenal 
ulcer in burns is thought by some to be due to thrombosis. 

Amyloid degeneration beginning in the fibrous wall of the 
small blood-vessels of the mucosa and submucosa is quite 
freciuentl}- met. 

Pigmentary infiltration is often met in old people. The 
muscularis is filled with a yellow pigment that does not con- 
tain iron. 

Hemorrhoids are varicose veins of the rectum. They may 
be either internal or external in character according to their 
relation to the sphincter ani. Are commonly the result of 
interference with the venous circulation. They may be due 
to cirrhosis of the liver, pressure from tumors, or from chronic 
constipation. The feces not only press upon the veins but 



DISEASES OF THE DIGESTIVE SYSTEM 339 

also give rise to a chronic proctitis that weakens the vessel 
walls. The hemorrhoids appear as small, dark bluish pro- 
jections which on section are found to be formed of dilated 
veins, between which is usually a formation of fibrous tissue. 
The cavity may occasionally become filled with fibrin and 
be converted into a fibrous mass. Hemorrhage frequently 
accompanies hemorrhoids, and infection with inflammation 
is also common. 

Inflammation of the intestine, or enteritis, may affect 
either the small or the large intestine or any portion of them. 
The mucosa and the submucosa are generally involved. If 
there is involvement of the stomach as well, the condition is 
known as gastro-enteritis. 

The inflammation may be caused by the presence of irri- 
tating substances within the gut, as indigestible materials or 
poisons of various kinds. It may also be due to the presence 
of certain organic bodies resulting from imperfect digestion 
and fermentation. 

Among the commonest causes of enteritis are the bacteria, 
such as the typhoid, cholera, and colon organisms. The in- 
testinal parasites, particularly the Amoeba coli, can occasion 
extensive inflammation. 

Catarrhal enteritis may occur in any portion of the intestine. 
There is usually a slight congestion with some swelling. The 
lymphoid follicles arc enlarged, there is considerable serous 
exudation, and occasionally small ulcerations. There is in- 
creased peristalsis on account of the inflammation and the 
intestinal contents are fluid as a result of the exudation. 
Shreds of epithehum may be discharged. In the intestinal 
wall there is a round-ceU infiltration of the mucosa, the 
lymphoid tissue is increased, and there is an abnormal num- 
ber of goblet cells. 

Follicular enteritis is frequently a sequel to the catarrhal 
form. In it there is marked involvement of the solitary 
lymphoid folhcles. They are much swollen, project from the 
mucous membrane, and sometimes undergo suppuration 
with the formation of ulcers. Is probably due to infection. 

Suppurative enteritis is characterized by the exudation of 



340 A MANUAL OF PATHOLOGY 

pus cells, with round-cell infiltration and focal abscesses in 
the mucosa and submucosa. May follow a follicular enter- 
itis and show numerous ulcerations of the follicles. 

Ulcerative enteritis may be due to suppuration of the 
lymphoid folHcles in catarrhal or follicular enteritis or to 
specific infection, as in typhoid, dysentery, tuberculosis, and 
syphihs. 

Pseudomembranous enteritis is characterized by the formation 
of a thick, grayish, soft and pulpy covering to the mucosa. 
Is most common in the large intestine on the edge of the 
valvukr conniventes. When the membrane sloughs off, 
there is left exposed an ulcer. The intestinal wall is thick- 
ened by edema, hyperemia, and round-cell infiltration. This 
form is generally seen in dysentery. 

Chronic enteritis may follow the acute form or it may 
depend upon the persistence of the cause of irritation. It 
generally involves the large intestine, particularly the de- 
scending colon and rectum. The mucosa is thickened, even 
to the extent of polypoid formations, the lymph-foUicles en- 
larged, and extensive connective-tissue hyperplasia is present. 
In between the elevated areas of mucosa there are depressed 
bands of fibrous tissue. The surface of the intestine is cov- 
ered by a tenacious mucus and the color of the tissue may be 
very dark on account of the venous congestion. Round-cell 
infiltration is marked. Instead of hypertrophy there may be 
an atrophy of the glandular tissue, on account of the con- 
traction of the fibrous tissue. These areas will be marked 
by the presence of dark almost black pigment. There is 
generally an atrophy of the muscularis as well. 

Clinical Manijestations. — All forms of enteritis are gener- 
ally accompanied by diarrhea as a consequence of the in- 
creased secretions and peristalsis. There is interference 
with digestion and nutrition and the general health of the 
individual suffers. Poisonous substances may form within 
the intestine. 

Duodenitis generally occurs in association with gastritis. 
On account of the resulting edema, the common bile-duct, 
which empties into this part of the intestine, becomes ob- 



DISEASES OF THE DIGESTIVE SYSTEM 



341 



structed and also inflamed, 
common symptom of duo- 
denitis. 

Typhlitis, inflammation 
of the cecum, is generally 
due to the retention of large 
masses of feces, although in 
many instances it accompa- 
nies an appendicitis. In- 
flammation may involve the 
surrounding tissues, perl- 
iyphlilis. 

Appendicitis, inflamma- 
tion of the appendix, is 
quite common. Thelumen 
of the appendix being so 
small, it is easily obstructed 
by foreign bodies or by 
edema. The blood-supply 
is poor, so nutrition is read- 
ily affected. Foreign bodies, 
as inspissated feces or seeds, 
may set up an irritation, but 
inflammation is more com- 
monly the result of the en- 
trance of micro-organisms, 
])articularly the colon ba- 
cillus. Their entrance 
may be facilitated by lesions 
of the mucosa caused by 
foreign bodies. The or- 
ganisms pass through the 
mucous membrane, pene- 
trate the lymphoid tissue, 
and set up an acute inflam- 
mation with round-cell in- 
filtration. Calarvhal appcn 
dicitis is characterized by 



This gives rise to jaundice, a 











Fig. 134. — Acute Appendicitis with 
Round-cell Infiltration and 
Hyperplasia of Connective 
Tissue in All of the Coats 
(Stengel). 
In large part the round cells of 

the mucosa and submucosa belong to 

the normal lymphoid tissue of these 

parts. 



342 A MANUAL OF PATHOLOGY 

slight swelling and minute erosions of the mucosa. The 
muscular and serous coats will show slight infiltration and 
the lumen will contain cpithehal and pus cells. In the 
necrotic or gangrenous variety the inflammatory processes are 
destructive. The mucosa is destroyed and the muscular and 
serous layers are soon attacked. The inflammation involves 
^neighboring surfaces and a fibrinous peritonitis develops. 
This may be local, and by giving rise to adhesions between 
adjacent tissues no further extension takes place. The pro- 
cess may be very rapid and perforation follow before any 
restricting adhesions form; this is accompanied by a general 
and frequently fatal peritonitis. 

In interstitial appendicitis there is a tendency toward 
excessive connective-tissue formation and it generally ter- 
minates as a chronic thickening. 

Appendicitis may recover spontaneously with nothing 
more than a slight thickening of the walls or obhteration of 
the lumen. Adhesions may form, and by interfering with the 
surrounding organs give rise to various disturbances. The 
appendix may rupture with local or general peritonitis or 
there may form a localized abscess. 

Colitis, inflammation of the colon, may be restricted to 
some one part of the colon, as the cecum, sigmoid flexure, etc., 
or involve all portions. It is generally due to the retention 
of large masses of hard feces, or to some of the infections, as 
tuberculosis and syphilis. Certain poisons, particularly the 
metallic, can set up severe inflammations; can also be due to 
products elaborated within the body, as in chronic nephritis. 
The mucosa is much thickened and there is a marked secre- 
tion of mucus. The mucosa frequently ulcerates and may 
become covered by a pseudo-membranous substance made 
up of desquamated epithelium and mucus. This may be 
passed from the rectum, in mass or as a cast {mucous colitis). 

Proctitis, or inflammation of the rectum, may be due to the 
presence of masses of hard feces, of foreign bodies, or to in- 
fections, as tuberculosis, syphilis, and gonorrhea. If acute 
in onset, it however soon becomes chronic. 

The mucous membrane is swollen, edematous, and minute 



DISEASES OF THE DIGESTIVE SYSTEM 343 

hemorrhages are frequent. Ulcerations of varying degrees of 
severity are present and may give rise to a periproctitis and 
perirectal abscesses. These may rupture externally and leave 
a fistulous tract opening both internally and externally; is 
known as fistula in ano. 

INFECTIOUS DISEASES 

Dysentery indicates an inflammatory condition of the 
colon and rectum characterized by ulcerations of the mucosa 
and the passage of numerous small, mucous, and bloody 
stools. It is a term that is applied to disturbances brought 
about by sev^al causes. It is most common in tropic and 
semi-tropic, bm occurs in the temperate zones as well. 

It may be due to the presence of the Amoeba coli, to the 
Shiga bacillus, or to various ferments and toxins of decom- 
posing meat ; sometimes it may follow the ingestion of poisons, 
particularly mercury. 

In the mild or catarrhal forms there is congestion and edema 
of the mucosa with some pctechiae. There is a slight increase 
in the secretion, and ulcerations may be found involving the 
solitary follicles. 

The ulcerative or amebic variety is much more severe. 
There is at first a marked nodular swelling of the mucosa. 
The mucous membrane at these points becomes necrotic and 
is cast off, exposing the infiltrated submucosa, which eventu- 
ally sloughs off. The resulting ulcers vary greatly in size and 
shape, but are all characterized by having a decidedly under- 
mined edge. Several ulcers may have communications 
beneath the mucosa and the ulcerations may extend to the 
serous covering. The amebae will be found in the lesions. 
The process tends to become chronic, and for a long time 
the amebae may be found in the stools, which also contain 
large amounts of pus. 

As the inflammation subsides the ulcerations begin to 
cicatrize and recovery takes place. There is usually quite 
extensive atrophy of the mucosa and sometimes distortions 
due to contraction of the healed ulcers. 



344 A MANUAL OF JPATHOLOGY 

The most common complication is abscess of the hver, 
which in amebic dysentery is usually single. 

There may secondarily result a diphtheritic dysentery; a 
variety in which there is formed a pseudo-membrane which 
occurs in varying extent. There may be numerous small 
areas so covered, or the entire colon and rectum may be in- 






h 



Fig. 135. — Dysentery of Large Intestine. X50 (Diirck). 

The superficial layers of the mucosa are necrotic. In the deeper layers 
between the glands many leukocytes have accumulated (i); 2, fibrinous 
thrombus in a small artery; 3, muscularis mucosae ruptured in many places 
by leukocytic accumulations; 4, submucosa with greatly dilated blood-vessels. 



volved. If the process is mild, the mucous membrane is 
alone affected; but if severe, the submucosa may be de- 
stroyed. 

The bacterial form of dysentery is, as a rule, much less 
severe in its manifestations than the amebic or tropical. 

As a result of dysentery there is a chronic thickening of the 



DISEASES OF THE DIGESTIVE SYSTEM 345 

large intestine, and rarely perforation occurs. Abscesses of 
the liver result from embolism. 

Asiatic cholera is an acute specific inflammation of the 
small and large intestines due to the comma bacillus or vibrio. 

The post-mortem appearances differ according to the time 
at which death occurred. Early in the disease, in the algid 
form, the intestine is rose-red or purple in color, the mucosa 
shows numerous petechial hemorrhages, and its surface is 
covered by a transparent layer of sticky fibrin. The con- 
tents of the intestine are thin, watery, and cloudy, and very 
copious. In it are many small flakes of desquamated epithe- 
lium which give rise to the "rice-water" appearance that is 
characteristic of the condition. The discharges are alkaline, 
have but little odor, and although some blood may be present, 
bile is seldom found. In this early stage the solitary and 
agminated lymph-follicles are enlarged and frequently un- 
dergo ulceration. The large intestine is generally hyper- 
emic, but otherwise negative. 

In later cases, after the algid stage has disappeared, 
the intestine is no longer reddish in color, and is nearly empty, 
except for the presence of a foul-smelling gas. At this period 
an enteritis with the formation of a pseudo-membrane fre- 
quently occurs. This is a result of the coagulation necrosis 
of the mucous membrane, particularly of the tips of the villi. 

The Peyer's patches are pigmented and bile may be found 
in the intestinal contents. The lesions are most marked 
in the lower portion of the small intestine, in which respect 
cholera dift'ers from dysentery and poisoning by the metallic 
salts, which involve the large intestine. 

In some cases there may be a hemorrhagic gastritis or an 
ulcerative colitis. 

In a person dying from cholera there will be hyperemia 
of the pia, hyperemia and parenchymatous degeneration of the 
kidney, and bronchopneumonia. The Hver and spleen will 
be smaller than usual. 

Early in the course of the disease the bacillus is present 
in the intestinal contents in great number, in a pure culture. 

Typhoid fever is an acute infectious fever caused by the 



346 



A MANUAL OF PATHOLOGY 




t 



J 



tiG. 13(1. — Iltum; i V- 
PHOiD Fever (Early 
Stage) (Nicholls). 
Peyer's patches and soli- 
tary follicles greatly swollen; 
superficial ulceration. 



B. typhosus, and its characteristic 
lesion is ulceration of the lymph- 
oid tissue of the small intestine, 
particularly the Peyer's patches. 
The upper part of the colon is also 
generally involved. 

The lesions in the intestine cor- 
respond closely to the clinical course 
of the disease and indicate by their 
appearance the duration of the in- 
fection. The organisms gain en- 
trance into the individual through 
the mouth in food, or more com- 
monly in the water. They pass to 
the small intestine and there give 
rise to the various lesions. At first 
the mucous membrane becomes hy- 
])eremic and swollen, the solitary 
follicles and the Peyer's patches be- 
come larger, their surfaces irregular 
and hyperemic. In the course of a 
few clays they fade and become 
cjuite pale or grayish-white as necro- 
sis begins. The Peyer's patch is 
elevated and sharply defined from 
the neighboring mucosa. Micro- 
scopically the intestinal wall pre- 
sents a high-grade round-cell infil- 
tration and an increase in epithelioid 
cells. During the second week there 
is a necrosis of the hyperplastic 
lymphoid nodes. The tissue is cast 
oft' in shreds. The greater part of 
the follicle may be sloughed oft", 
leaving a long, irregular ulcer with 
a smooth floor lying parallel to the 
long axis of the intestine. The ul- 
cers usually appear toward the end 



DISEASES OF THE DIGESTIVE SYSTEM 



347 



of the second week of the disease. They extend to varying 
depths; in some cases involving the lymphoid tissue alone, 
but at times the necrosis passes on to the submucosa and 
even to the serous covering. Perforation is common. Ulcer- 
ation is most marked in the small intestine near the ileocecal 
valve. 








.mm..- - ■ •- 



■'■■■'■r:r:--' .^:.- 



M 



mb 



f^:: 






'9^^x: 









'S'^i 



OF Slough. X50 



Fig. 137. — Typhoid Ulcer after Detachment 

(Durck). 

The margins of the defect end abruptly; in the floor of the ulcer, which 
reaches into the submucosa, are seen a few necrotic portions of tissue with 
extensive infiltration of leukocytes, i, Mucosa; 2, muscularis mucosae; 
3, submucosa with overfilled blood-vessels; 4, muscularis. 



By the end of the third week the necrosis and ulceration 
ceases and reparative processes begin. The hyperplastic 
lymphoid tissue resumes its normal condition by disintegra- 
tion and absorption of the newly formed cells. The ulcerated 
surfaces heal by cicatrization and by extensions from the 
surrounding mucous membrane. 



34^ A MANUAL OF PATHOLOGY 

The increase in the ceUular elements in the lymph-nodes 
is the result of the ])roliferation of the endothelial cells of the 
lymphatic spaces, blood-capillaries, and reticulum of the 
lymphoid tissue. It is brought about by the action of a toxin. 
These cells give rise to necrosis in the lymph-nodes, Hver, and 
spleen by thrombosis which interferes with the blood-supply. 
They may be found in the lung. 

The complications of typhoid fever are several, but the 
most serious are hemorrhage and perjoralion. Small hem- 
orrhages may be the result of oozing from the ulcerated sur- 
faces. Its presence causes the stools to be dark brown in color. 
Severe hemorrhage follows the destruction of the walls of 
some larger vessel. It may remain in the intestine long enough 
to undergo changes and give rise to the "tarry stools." 
Occasionally the loss may be so sudden and large that the 
blood is discharged when still bright in color. Perforation 
follows extensive ulceration, and may occur by the end of the 
second week, but usually later during the third. The in- 
testinal wall may have become so thin that solid substances 
may lacerate it and escape into the peritoneal cavity. If the 
process has been comparatively slow, adhesions may have 
formed so as to prevent a general infection. If this has 
not happened, general purulent peritonitis, nearly always 
fatal, will be set up. 

The mesenteric lymph-nodes become enlarged, soft, and 
hyperemic. As the processes within the intestine increase 
in severity these nodes show fatty metamorphosis, softening, 
and even necrosis. The spleen becomes much larger, soft 
and flabby, and hyperemic. Sometimes it will be the seat of 
infarctions and abscesses. The muscles, particularly the 
recti, show Zenker's degeneration, a hyaline change. Minute 
hemorrhages may also be present in the muscles. The heart 
muscle undergoes a certain amount of cloudy swelling and 
at times is the seat of acute myocarditis. Acute endocarditis 
occasionally occurs, but is not as common as in other in- 
fectious diseases. There is no leukocytosis present unless 
pneumonic inflammations have arisen; acute broncho- 
pneumonia and crou})ous pneumonia are quite common com- 



DISEASES OF THE DIGESTIVE SYSTEM 349 

plications. The kidneys are quite commonly the seat of acute 
parenchymatous nephritis and areas of focal necrosis are also 
frequently observed. Hemorrhagic areas may be found. 

The bacilli are present not only in the intestine but else- 
where. Early in the disease they can be readily obtained 
from the blood. They are found in the skin lesions, the 
"rose spots," also in the urine. The internal structures, as 
the spleen, mesenteric nodes, and gall-bladder, contain them. 
The organisms may remain within the body for a long time 
after convalescence and then give rise to suppuration, as 
ostitis, parotitis, and meningitis. 

Pulmonary tuberculosis is a not uncommon condition 
occurring after the patient has apparently entirely recovered. 

An important test in the making of the diagnosis of 
typhoid fever is the Widai reaction. It is based upon the 
principle that when the blood of a patient suffering from 
typhoid fever is added to a fresh culture of the typhoid or- 
ganism the bacilli will gather into clusters and gradually 
lose their motility, a process known as "clumping." The 
reaction is performed as follows: The most satisfactory way 
is to obtain the blood in a fresh state, and if one can get a 
sufficient amount to allow the use of the scrum alone, it is 
even better. A drop of blood, or serum is forced out of a 
capillary tube, in which it should be received, and to this 
nine drops of sterile water are added. This is thoroughly 
mixed, and one drop of this mixture added to one of the 
culture gives a dilution of i : 20. The culture to be used 
that is generally recommended is a bouillon one not more 
than twenty-four hours old. Some authors recommend a 
fresh agar culture, but there is danger of the bacilli being 
already clumped to some degree. Dilutions of i: 10 and 
I : 50 should also be employed as control tests. A drop of 
this solution is placed on a cover-glass, which is then inverted 
over a hollow-ground slide. The reaction is said to be 
positive if within forty-five minutes the bacilli are found to be 
gathered in little groups and their motihty almost or entirely 
absent. 

If the blood cannot be sent fluid, several drops of blood 



350 



A MANUAL OF PATHOLOGY 



should be placed on a sterile slide and when dry sent to the 
laboratory. One of the drops is dissolved in a drop of sterile 
water and then diluted till the proportion is one to tifty. The 
rest of the technic is the same as with the fluid blood. 

This reaction, although generally seen within forty-eight 
hours after the onset of the disease, may be delayed till much 
later. It may also appear in those who have suffered from 
typhoid fever some time previously. 

ParatypJwid fever presents lesions that differ somewhat 
from tvphoid. There are not the characteristic intestinal 




Fig. 138.— Tubkrcular Ulceration of the Intestine (Stengel). 



changes. The clinical appearance may be similar, but 
there may be no ulcerations present in the intestine or else 
the ulcers may be very irregular and not typical. Two 
strains of organisms very closely related to each other, but 
differing in certain respects in their cultural characteristics 
from the typhoid bacillus, have been isolated. 

Tuberculosis of the intestine is common in children as a 
primary infection; in adults it is frequently secondary to 
pulmonary and laryngeal tuberculosis. In children the 



DISEASES OF THE DIGESTIVE SYSTEM 35 1 

source of infection is probably tubercular milk. The con- 
sensus of opinion at present is that the tubercle bacillus found 
in the milk of diseased cows is quite capable of infecting the 
human organism. The infection in adults is generally due 
to the swallowing of sputum. 

The lymphoid tissue in the lower portion of the ileum 
is the usual seat of the primary lesion. There is the forma- 
tion of a tubercle with coagulation necrosis; the central por- 
tion is cast off and an ulcer with thickened edges and a yellow- 
ish base is formed. Several ulcers become confluent and a 
large irregular one results. Instead of remaining the shape 
of the Peyer's patch, the ulcer tends to increase in size laterally, 
unlike the typhoid lesion. This is due to the extension by 
means of the lymphatics which surround the intestines. The 
lesion usually involves the submucosa as well as the mucosa, 
also the muscularis and sometimes the serous coat. As a 
rule, the peritoneal covering at the site of the ulcer is the seat 
of numerous small tubercles in clusters. There may also 
l)e found white lines connecting neighboring tubercles; 
these are probably lymph- vessels that arc stopped up by 
caseous matter. 

Pevjoration is the most dangerous complication, but it does 
not frequently occur, on account of adhesions that have been 
formed during the progress of the disease. Tubercular 
peritonitis may result from tuberculosis of the intestine. 
The ulcers may be present in all stages, some completely 
healed while others are undergoing active changes. As a 
result of the position of the ulcer the cicatrization is more 
likely to be followed by stenosis than is the case in typhoid 
fever. The mesenteric nodes are usually involved and at 
limes may show much more marked disease than is seen 
within the intestine. 

Syphilis of the intestine is seldom met with, and when 
seen usually appears in the rectum. The small intestine 
may be involved in cases of congenital syphilis. Small 
gummata are seen which show a marked tendency to undergo 
softening and ulceration; the lymphoid tissue being generally 
the site of the lesions. The rectal form is usually the result 



352 A MANUAL OF PATHOLOGY 

of direct infection and the disease may appear as the primary 
chancre, as papules and mucous patches in the secondary 
stage, and as gummata in the tertiary. In the third stage 
there may be such extensive ulceration as to destroy the 
mucous membrane almost completely for several inches along 
the bowel. The wall of the intestine at the seat of ulceration 
may become much thickened by a round-cell infiltration. 
Following this extensive ulceration, cicatrization with con- 
traction and stenosis may occur. 

Actinomycosis and leprosy very rarely appear. Anthrax 
sometimes involves the small intestine. Is found in wool- 
sorters, brush-makers, and others exposed to infection. 
The mucosa and submucosa show hyperemia and a hemor- 
rhagic edema, and extensive ulceration appears. The 
tissues are dark colored and necrotic and the ulcers are sur- 
rounded by a zone of hemorrhagic infiltration. The adjacent 
lymph-nodes and the spleen are enlarged; and the anthrax 
bacillus can be found in greatest numbers in the locality of 
the necrosis. 

Enteromycosis refers to a condition in which there is an 
infection of the intestine by the eating of decayed proteid sub- 
stances, as putrid meat, fish, sausages, and so on. Sometimes 
occurs in epidemics. The intestinal lesions vary from a mild 
catarrhal enteritis to a pseudo-membranous inflammation and 
ulceration. Is accompanied by diarrhea and depression. 
The symptoms, both constitutional and local, probably 
depend upon the action of toxins elborated in the decaying 
matter rather than upon the bacteria themselves. 

Tumors. — Connective-tissue growths are unusual and 
generally benign. Fibroma, lipoma, and myxoma are some- 
times seen. They may cause some obstruction if large. 
Sarcoma is rare. It arises within the submucosa and ex- 
tends very rapidly, elevating the mucosa. Is generally 
round-cell in character and may with difficulty be distin- 
guished from the lymphatic enlargements that are present in 
the intestine in leukemia and Hodgkin's disease. 

Epithelial tumors are more common and not infrequently 
cause death. Adenomata are quite common, and may be 



DISEASES OF THE DIGESTIVE SYSTEM 353 

diffuse or of a polypoid nature. They originate from the crypts 
of Lieberkiihn, as a rule. The polypoid form is more common 
in the rectum and may undergo inflammatory changes as a 
result of injury by the feces. 

Carcinoma is the most common of the intestinal tumors 
and is usually composed of cylindric cells. It is most fre- 
quent at certain sites, as the papilla of the common bile-duct, 
the ileocecal valve, the hepatic, splenic, or sigmoid flexures, 
and within the rectum. It is somewhat elevated, its surface 
rough, irregular, and ulcerated, and it involves the entire 
lumen of the gut, causing obstruction. Bleeding from the 
ulcerated surface is quite common. If the connective-tissue 
stroma predominates the growth is hard and firm; if very 
cellular, it is soft, whitish, and spongy. These tumors show 
a marked tendency to undergo mucoid and colloid degenera- 
tions, and metastases to the neighboring lymph-nodes and 
liver are common. 

Squamous epithelioma originate at the anus and may in- 
volve neighboring structures. 

Parasites of both animal and vegetable types are common 
occupants of the intestine. Of the animal parasites, the round 
worms, as the iVscaris lumbricoides, Oxyuris vermicularis, 
Trichocephalus dispar, Anguillula intcstinalis and stercoralis, 
and Eustrongylus gigas; the tape- worms, Taenia solium, 
T. saginata, T. echinococcus, and Dibothriocephalus latus; 
and the sucking-worms, the Uncinaria, are found present 
under various circumstances. 

Other and more unusual forms arc the Cercomonas, 
Trichomonas, Balantidium coli, and the Amoeba coli. 

Foreign bodies of innumerable varieties have been swal- 
lowed and subsequently found within the intestine. Some- 
times dense masses of fecal concretions, enteroliths, are found. 
These are composed of a nucleus of epithelium, hair, or 
other foreign bodies, surrounded by dried fecal matter. 
They may give rise to local irritation. In the lower animals 
they are of large size, but in man are generally smaU. 

Tympanites or meteorism is a condition of dilatation of the 
intestine by the presence of a large amount of gas. It may 
23 



354 A MANUAL OF PATHOLOGY 

be so severe as to cause a paralysis of the muscular coat with a 
cessation of peristalsis. 

DISEASES OF THE LIVER 

Malformations are not common and seldom of im- 
portance. Complete absence is seen in acardiac monsters. 
Variations in the number of lobes and in the fissures may 
occur. Portions of hepatic tissue may be separated from the 
main mass, but are usually connected by a pedicle of con- 
nective tissue. Malformations may be acquired particularly 
as a result of tight lacing, which causes a deep transverse 
notch upon the anterior surface which may almost divide 
the organ, the hepatic tissue along the line of pressure under- 
going atrophy. 

The position of the liver may be changed by relaxation of 
its hgaments or by pressure from tumors within the abdomen. 

The ribs posteriorly and the right crus of the diaphragm 
may by pressure form long furrows. 

Disturbances of Circulation. — The liver is peculiar in 
its blood-supply in that it contains two systems. One of 
these, the lesser, supplies nutrition to the stroma ; the other, 
which is of much greater importance, supphes the blood nec- 
essary for the carrrying on of the hepatic functions. This 
latter, the portal system, divides into many branches that 
ramify throughout the acini and empty into the central veins 
of the lobules, branches of the hepatic. The blood flows very 
slowly through the organ and is under very little joressure, 
consequently is readily interfered with by slight obstruction. 

Anemia may be part of a general anemia or may be due to 
pressure upon the blood-vessels. The organ is pale, but 
may vary in color according to the amount of bile or of fatty 
degeneration present. 

Active hyperemia occurs normally during digestion, and is 
also present as an accompaniment of inflammation, in 
which case the areas are circumscribed. May be general as 
a part of an infectious process. The organ is slightly en- 
larged, softer, dark red in color, and on section blood readily 
escapes. 



DISEASES OF THE DIGESTIVE SYSTEM 



355 



Passive hyperemia is of greater pathologic importance 
than the active. It is caused by interference with the escape 
of the blood into the vena cava. Is found in valvular 
diseases of the heart, in those conditions interfering with 
the pulmonary circulation, as emphysema, chronic fibroid 




Fig. 139. — Nutmeg Liver: Chronic Congestion due to Cardiac 
Disease (Bollinger). 



phthisis, etc., and to pressure upon the vena cava by tumors. 
Pleural effusions with adhesions may cause it. 

As a result of the obstruction to the circulation the central 
vein of the lobule first becomes dilated, and subsequently 
the capillaries in communication. Following this continued 



356 A MANUAL OF PATHOLOGY 

pressure there is atrophy of the cells in the central zone and 
at times even of those as far out as the periphery of the lobule. 

The organ is at first enlarged, the anterior edge rounded, 
and may be darker in color. On section is seen the char- 
acteristic reddish-brown and yellow mottling known as the 
''nutmeg liver." The reddish-brown areas represent the 
deeply congested portion surrounding the central vein, while 
the yellow indicate a fatty degeneration and infiltration of the 
peripheral cells. In between these two zones there is a less 
marked area in which the cells are atrophic and contain dark- 
brown pigment. 

If the congestion has been present for a long time the 
organ may become smaller on account of atrophy of the he- 
patic cells. The surface of the liver becomes uneven, due to 
hyperplasia of connective tissue, and is darkly pigmented, 
a condition known as cyanotic induration. 

In some cases there is a deposit of hematogenous pigment 
throughout the organ, causing it to be dark red. Such a 
change is spoken of as red atrophy, as the liver is smaller than 
normal. 

As a result of chronic congestion the action of the liver may 
be much interfered with, one of the most common symptoms 
being shght jaundice, probably due to the obstruction of the 
bile-ducts and capillaries by the swollen endothelial cells. 
The bile is also generally more viscid than normal. 

Embolism and thrombosis not infrequently occur and cause 
greater or less disturbances according to their location and 
magnitude. As a rule, no serious conditions arise, as the 
collateral circulation is so extensive. The hepatic artery is 
capable of supplying sufficient blood for both the nutrition 
and function of the organ, so that marked interference with 
the portal circulation does not necessarily result seriously. 
If the portal vein is completely obstructed, the secretion of 
bile stops, the blood is retained in the portal system, and 
death may result. If the hepatic artery is obstructed the 
liver rapidly becomes necrotic. 

Numerous small foci of necrosis may result from infectious 
emboli in the portal capillaries. Is known as jocal necrosis 



DISEASES OF THE DIGESTIVE SYSTEM 357 

and is seen in puerperal fever, and in septic conditions in- 
volving the portal system, also in various infectious diseases. 
These foci differ in color from red to yellow according to 
whether blood or fat is present in the greater amount. The 
interlobular portal vessels are frequently the seat of a hyaline 
thrombosis. 

Infarctions of the liver, either hemorrhagic or anemic, are 
almost unknown, as the anastomoses of the hepatic vessels are 
so extensive. 

Hemorrhage of the liver occurs in severe infections and in- 
toxications. 

INFILTRATION AND DEGENERATION 

Pigmentation of the liver may be hematogenous. The 
blood coloring-matter may not be completely transformed 
into bile-pigment and is deposited in the interlobular tissues, 
in the peripheral zones, and in the central area of the lobule. 
This occurs to some degree in nearly all diseases of the liver. 
Is marked in chronic congestion, amyloid disease, cirrhosis, 
and pernicious anemia. The pigment is found as dark 
brown granules, is probably hemosiderin, as its gives the iron 
reaction a blue color when pure sulphuric acid and potassium 
ferrocyanid are added. 

Biliary pigment due to the retention of bile is not un- 
common. The liver becomes dark yellowish-green, at times 
almost black in color. Is most marked in the central zone of 
the liver lobules. 

Pigment in the form of melanin resulting from blood de- 
struction in chronic malaria, and also as anthracotic particles, 
is found occasionally. 

Fatty infiltration is to a certain extent normal, is more 
marked the younger the individual. After a meal, parti- 
cularly if rich in fat, there is an infiltration in the peripheral 
zones. This is soon removed if the hei)atic functions are 
being carried on normally. If the oxidation does not take 
place properly the fatty infiltration may become of an ex- 
tremely high grade. Is best seen in chronic tuberculosis, 
particularly if forced feeding has been indulged in; in 



35^ A MANUAL OF PATHOLOGY 

marasmatic individuals and in alcoholics, especially when 
malt liquors have been consumed to excess. 

The liver becomes much enlarged, is at times nearly twice 
its normal size; the edges are rounded, its color is a uniform 
yellow, and it is doughy, slight pressure causing an indenta- 
tion. On section the knife will be covered with small drop- 
lets of fat. The center of the acini may be darker than the 
periphery on account of congestion. The cells, microscopi- 
cally, are seen to contain comparatively large droplets of fats 
which show a marked tendency to coalesce and form one 
large drop which may greatly distend the cell and push aside 
its nucleus, giving rise to the ''signet-ring" appearance. 
The infiltration begins in the periphery and extends inward. 
On account of the distention of the cells the blood-vessels 
may be hidden from view and so obstructed as to give rise to 
considerable anemia and diminishmcnt of functional activity. 

The cells in this condition do not appear to be much 
damaged and are apparently able to resume their work 
when the fat disappears. 

Parenchymatous degeneration or cloudy swelling 
occurs in most of the infectious fevers and in intoxications. 
The liver is somewhat enlarged and grayish-yellow in color. 
Microscopically the cells are seen to be swollen and filled 
with albuminous particles which obscure the nucleus. The 
organ readily recovers if the exciting cause passes away, 
otherwise fatty degeneration will ensue. 

Fatty degeneration or metamorphosis occurs in severe 
anemias, in phosphorous and arsenic poisoning, and in cer- 
tain of the infections, as yellow fever. The liver is smaller 
than normal, yellow in color, and soft. Oil drops exude 
from the cut surface. Microscopically the cells are seen to 
contain numerous minute fat granules that do not, as a rule, 
tend to coalesce. Is most marked in acute yclloiv atrophy of 
the fiver. In it the liver is greatly decreased in size, the edges 
thin, its color uniformly yellowish or streaked with brown, 
and is very soft, so much so that it may not retain its shape. 
The capsule is much wrinkled. On section the tissue in 
many places seems almost liquid while elsewhere it is firmer 



DISEASES OF THE DIGESTIVE SYSTEM 359 

and darker in color. Oil fairly drips from the surface. 
Microscopically the cells are seen to have undergone extreme 
metamorphosis, and to have been replaced by pigment. The 
hepatic tissue may be completely destroyed to a great extent; 
the degenerated material is absorbed and the decrease in 
size results. 

Occasionally bright red or dark red areas arc present. 
These represent foci of hemorrhagic infiltration or pigmenta- 
tion. 

The causes of this condition are practically unknown. 
It is most common in young women. It appears in infectious 
fevers, particularly puerperal, in syphilis, in phosphorous 
poisoning, and again without any apparent cause. Alicro- 
organisms of many kinds have been found in the bile-vessels 
and in the hepatic tissue, but no specific one has been iso- 
lated. Some authors think it due to the absorption of toxins 
from the intestine. 

The destruction apparently begins in the peripheral zone 
around the portal vessel and extends toward the center. 

The urine contains leucin and tyrosin. 

Amyloid degeneration of the liver results from long- 
continued su})puration, as in chronic tuberculosis, in suppura- 
tive bone diseases, and is usually accompanied by similar 
degeneration elsewhere. The liver is larger than normal, 
a little pale in color, and is quite firm. The cut surface fre- 
quently appears c^uite translucent and may be a grayish- 
white or a dull yellow color. 

The degeneration begins in the wall of the capillaries, which 
become much thickened; so much so that the blood-supply 
may become obstructed. Pressure is also exerted upon the 
adjacent liver-cells, many of which undergo atro])hy. The 
peripheral zone is the one in which the change is first noticed, 
and from there it extends toward the center of the lobule. 
The connective tissue is also involved and the aft'ected areas 
may become very extensive. As the epithelium is involved 
secondarilv the orsjan is able to carrv on its function as long 
as a sufiicicntly large number of cells do not become atrophic. 

Edema of the liver occurs in the course of long-continued 



360 A MANUAL OF PATHOLOGY 

circulatory disturbances and in severe infections. The tissue 
is swollen and many of the cells may contain vacuoles. 

Atrophy as a primary condition depending upon local 
anemia is rare. Is quite common as a secondary lesion, 
depending upon pressure, such as tight lacing, or that re- 
sulting from the contraction of cicatricial bands. The organ 
becomes irregularly atrophic, the cells in the involved areas 
are distorted, irregular, granular, and pigmented. The 
nuclei generally break down. 

In leukemia there are collections of leukocytes in the con- 
nective tissue in between the lobules. 

Acute interstitial inflammation of the liver usually 
follows upon acute infectious conditions elsewhere, parti- 
cularly in the intestines, but may be due to trauma. Is always 
suppurative in character and may appear as a single large 
abscess or as numerous small ones. The exciting micro- 
organism may gain a foothold in the hver by means of (i) the 
portal vein, (2) the hepatic artery, (3) the hepatic veins, (4) 
the umbihcal vein in the new-born, (5) the bile-ducts. 

The organisms lodging as emboli within the capillaries 
set up a focus of suppuration. 

Infection from amebic dysentery- generally gives rise to a 
single large abscess in the right lobe. The pus contained 
within such differs from that onhnarily found in that it is 
grayish or pinkish in color, and mucilaginous in consistency. 

In bacillary dysentery numerous miliary suppurative foci 
are found. 

In suppurative thrombophlebitis (pylephlebitis) the puru- 
lent process follows along the course of the infected vessels, 
where it can be seen in the form of soft, white lines of suppura- 
tion with inflammatory reaction in the adjoining tissue. 

The liver- cells degenerate, lose their nuclei, and become 
necrotic. At the same time there is extensive round-cell 
infiltration within as well as around the lobules. Pus cells 
soon appear and a small focus of suppuration is formed. 
This process may continue until a large abscess results. 

If the abscesses are small the organ may regain an approxi- 
mately normal condition through absorption of the pus with 



DISEASES OF THE DIGESTIVE SYSTEM 



361 



cicatrization. Large abscesses may very slowly become 
absorbed and their walls much thickened ; lime salts may be 
deposited. 

Instead of a favorable termination the abscess may rupture 
into the abdomen, into the thorax, or if adhesions have 
formed through the abdominal wall. 





.^■'.f/ 




Fig. 140. — Atrophic Cirrhosis of the Liver. X 40 (Durck). 

Well-marked bands of connective-tissue (2) divide the parenchyma of 
the liver into irregular islands of varying size; even in the larger of these 
there is no division into lobules (i). Vena centralis absent in some places; 
in others, excentric (upper right corner). 3. Smaller islands of liver cells. 
Scattered heaps of round cells in the connective tissue and toward the left 
a few epithelial canals with darkly colored nuclei (newly formed bile-ducts). 



Chronic interstitial hepatitis is characterized by an over- 
growth of fibrous connective tissue supposed to be due to the 
long-continued action of some mild irritant. Alcohol is 
thought to be the commonest cause. 

The more usual form is that resulting from the irritating 
substance being conveyed in the blood, hematogenous; a 



362 A MANUAL OF PATHOLOGY 

second and rare form is the hepatogenous, one in which the 
changes follow upon an obstruction to the bile-vessels. 

Atrophic Cirrhosis [Laennee's Cirrhosis, ''Hoh-naiV^ 
Liver). — Is hematogenous in character, as in the majority of 
cases it is due to the presence in the circulation of a poisonous 
substance formed by distilled liquors. Early in the disease the 
organ may be somewhat enlarged, but in the typical stage the 
liver is small, contracted, the surface irregular, the color 
varying greatly, is very hard, dense, and cuts with great 
di faculty. The nodules that project are composed of liver- 
cells, while the depressed areas are formed by bands of con- 
nective tissue that have contracted. These bands are grayish 
in color, the elevated portions yellowish or brownish, the 
color depending upon the fatty degeneration or the presence 
of bile. 

Microscopically the process begins as a localized in- 
filtration of round cells about the interlobular branches of 
the portal vein. This is followed by a proliferation of the 
connective tissue with the formation of new fibers. These 
increase in number, and undergoing contraction interfere 
with the circulation. This gives rise to certain associated 
symptoms, as ascites, gastro-intestinal catarrh, hemorrhoids, 
and distention of the superficial abdominal veins (the caput 
meduScT). Jaundice is seldom present. The entire lobule 
eventually becomes surrounded, and as the contraction con- 
tinues the hepatic cells undergo atrophy till at last there may 
be an island composed of a few epithelial elements. The 
connective tissue does not tend to become intralobular. 

Associated with the above changes is more or less marked 
fatty degeneration. An important feature in this disease is 
the prohferation of bile-ducts in the interlobular connective 
tissue. There is usually a decided increase in their number. 

Sometimes the liver-cells may contain large amounts of 
pigment granules, varying in shade from yellow to dark 
green; may be hemosiderin or bile-pigment. 

Hypertrophic cirrhosis {Hanoi's cirrhosis) derives its 
name from the fact of the liver being much larger than 
normal. 



DISEASES OF THE DIGESTIVE SYSTEM 363 

Its surface is smooth or finely granular, dense and firm, and 
cuts with difficulty, but not with so much as in the atrophic 
form. The cut surface shows usually a decidedly mottled 
appearance, areas of yellow, gray, and green being inter- 
mingled. The connective tissue is not seen in bands sur- 



^^^^^^^.U^^^ 









(■: ■• '. ■ •.^.•■ '.<♦♦-.■• - .."^ . ;> 



* 






\ 



■'■■;'>)"!.(€,'^--''i;:y,*' 

.• . ; "•'.■'" " * ' ■' *"• '■■"'■'■" • - >i 
* ■ ' , •• .. ' ." ■' •'<* 

.■■'■■■>. , ' •■"■■■'*: •.■>„.-': ■■'i? 



Fig. 141. — Chronic Indurating CiRRnosis of the Liver (McFarland). 
a. Liver lobule, most of whose cells are in a faUy infiltrated condition; 
b, greatly hypertrophied periportal connective tissue; c, proliferated bile- 
ducts. 



rounding islands of livcr-ccUs, but occurs in a diffuse arrange- 
ment. It does not tend to contract and interference with the 
portal circulation is unusual. 

Microscopically the new-formed connective tissue is seen 
to extend into the lobules between the columns of cells as 
well as in the interlobular areas. The bile-ducts are increased 



364 A MANUAL OF PATHOLOGY 

in number and many of them are seen to be obstructed by 
broken-down cells and pigment. Surrounding them is an 
increase of connective tissue, a periangiocholitis. The num- 
ber of bile-ducts may be so great as to give rise to a con- 
dition resembling an adenoma or even a carcinoma. 

On account of the obstruction to the ducts jaundice is 
present and the liver may be dark green in color. 

Atrophic Cirrhosis. Hypertrophic Cirrhosis. 

(Laennec's.) (Charcot's.) 

Small. Surface uneven, Large. Surface smooth, 
pale. mottled green. 

Connective tissue surround- Connective tissue generally 
ing acini. diffused and extending 

into acini. 

Ascites appears early and Appears late if at all. 
often severe. 

Jaundice rarely present. Jaundice comes on early 

and is very marked. 

Hemorrhoids common. Unusual. 

Biliary cirrhosis is a condition in which there has been 
an overgrowth of connective tissue as a result of obstruction 
of the large bile-ducts. The congestion of the bile in itself 
acts as an irritant, but there is usually an infection by micro- 
organisms from the intestine. The liver becomes swollen 
and inflammatory reactions appear. The surface is smooth 
and the tissue is deeply stained by the ])ile. The peripheral 
zones of the acini show small areas of necrosis which may be- 
come transformed into minute abscesses if bacteria are 
present. Instead of suppurating the necrotic areas may be 
replaced by connective tissue and give rise to widespread 
induration that closely resembles hypertrophic cirrhosis. 

The bile-ducts may increase in number and evidences of 
regeneration of the hepatic cells are shown by the presence 
of mitotic figures. 

This form generally follows obstruction of one of the 
larger hepatic ducts or of the common duct. If the ob- 



DISEASES OF THE DIGESTIVE SYSTEM 



365 



struction has been complete, rapid fatty degeneration and 
acute atrophy may occur. 

Perihepatitis or inflammation of the capsule of the liver 
may be present in cirrhosis and as a result of chronic periton- 
itis. The capsule may become greatly thickened and by 
contraction bring about atrophy of the hepatic tissue immedi- 
ately underlying. 




Fig. 142. — (Hypertrophic) Diffuse Cirrhosis of the Liver. X 160 

(Durck). 
Lobular marking lost, the liver tissue separated into narrow strands 
by proliferating young connective tissue with short fibers, in which are 
wide capillaries with distinct endothelium. 



Rupture of the liver usually results from direct injury. 
Is more commonly seen in the newly born when there has 
been instrumental interference. 

INFECTIOUS DISEASES OF THE LIVER 

Tuberculosis of the liver is secondary to lesions of the 
disease elsewhere and may have become infected through 



366 A MANUAL OF PATHOLOGY 

either the blood or the lymph-channels. It appears generally 
as miliary tubercles scattered throughout the organ, or as 
larger necrotic foci. 

Microscopically the lesions are the same typical ones as 
are found everywhere in the disease. 

Rarely there is a single large cheesy focus. 

Syphilis of the liver is a common involvement in that 







Fig. 143. — Miliary Tuberculosis of the Liver. X 70 (Diirck). 
Two foci, consisting of smaller confluent tubercles, which are still 
distinguishable. The giant cells are rounded. The foci are situated in 
the periportal tissue in the vicinity of a portal branch. 

disease. In adults who have acquired syphihs there is 
frequently a diffuse proliferation of connective tissue with 
atrophy of the hepatic cells that closely resembles atrophic 
cirrhosis. Generally the disease manifests itself in the form 
of locahzed proliferations of connective tissue that divide the 
liver into numerous small but well-defined lobes. A certain 
area may become almost constricted off from the rest of the 
organs. The irregular distribution of the connective tissue is 



DISEASES OF THE DIGESTIVE SYSTEM 367 

the characteristic feature. This form probably originates as 
an inflammatory thickening about the portal veins and the 
bite-ducts. 

Gumma may also be present in acquired or congenital 
syphilis, either singly or in numbers. In the acquired form 
the single ones are usually the larger. They occur as rounded 
yellowish masses, the center of the larger ones frequently be- 
ing the seat of coagulation necrosis. Surrounding them is 
a zone of hyperemia and there is generally some connective- 
tissue hyperplasia. This occurs in the form of bands radiat- 
ing from the center, giving a characteristic stellate appear- 
ance to the resulting scar. 

Congenital syphilis of the liver may manifest itself in a 
diffuse form or as gummata. In the diffuse variety there is 
a widespread connective-tissue proliferation and round-cell 
infiltration. The organ is yellowish or brown, sometimes 
larger than normal, and extremely firm, almost like sole 
leather. The round-cell infiltration is found in the neigh- 
borhood of the blood-vessels, even being seen within the 
walls. The liver epithelium is frequently the seat of fatty 
degeneration, giving rise to the ''acute yellow atrophy" of 
the liver of the new-born. 

The congenital gummata are not, as a rule, circumscribed. 
They are found in the interlobular tissue and may be located 
within the wall of a blood-vessel or of a bile-duct. 

Leprosy is sometimes found in the liver, where it occurs 
as granulomatous masses containing the characteristic giant 
cells and bacilli. 

Actinomycosis rarely occurs in the liver. When present, 
it is generally due to secondary involvement by extension 
from the lung. 

Tumors. — Primary grow^ths of the liver are very un- 
usual, but it is nearly always involved secondarily in malignant 
disease of other localities. 

Angioma is about the most frequent new growth. It 
generally occurs upon the surface of the liver as small, cir- 
cumscribed, dark red or purplish areas that may be single 
or multiple. Sometimes they may be as large as an orange. 



368 A MANUAL OF PATHOLOGY 

They are more common in old, poorly nourished people. 
The surrounding liver tissue shows no changes. Microscopic- 
ally the structure is that of a cavernous angioma. 

Fibroma, Lipoma, and Myoma are very rarely met with. 

Sarcoma may be primary or secondary, the latter being 
the more usual. 

The primary variety is more frequently found in children. 
It develops from the connective tissue of the hilus or of the 
periportal tissue and appears either as a round-cell or a 
spindle-cell growth. 

Secondary sarcoma follows as a hematogenous infection 
from a primary focus elsewhere, and is formed of the same 
variety of cells as the original growth. Melanotic growths 
are commonly secondary to sarcoma of the eye. 

The liver is increased in size and is the seat of numerous 
rounded masses varying in size and pale in color. 

Adenoma is found in livers that are otherwise normal, and 
also in cases of cirrhosis. May be single or multiple, nodular, 
somewhat encapsulated, and grayish or pinkish in color. At 
times it may be difficult to distinguish adenoma and cirrhosis 
from carcinoma both by the naked eye and by the microscope. 

Hypernephroma, a variety of adenoma that develops from 
a misplaced fragment of adrenal tissue, is but rarely seen. 
The cells in this form are cubical and contain fat and 
pigments. 

Carcinoma may be primary, which is uncommon, or sec- 
ondary, which is the usual form. 

Primary cancer may appear as a large, more or less cir- 
cumscribed tumor, usually in the right lobe. It probably 
originates as an adenoma and extends into the surrounding 
tissues. Microscopically there are seen irregular cell nests sur- 
rounded by a well-marked connective-tissue framework. 
The cells resemble the liver parenchyma, as a rule, but in 
places they arc smaller and more closely simulate the cells 
of the bile-ducts. Fatty degeneration and necrosis are com- 
mon, and pigment, either bihary or melanotic, is not infre- 
quently present. 

Another variety of the primary growth occurs as a diffuse 



DISEASES OF THE DIGESTIVE SYSTEM 369 

carcinomatous infiltration with a general increase in the size 
of the organ. The surface of the liver is granular and nodu- 
lar, and grayish or brownish in color. Larger circumscribed 
nodules may also be present. Except for the large nodules, 
the appearance of the organ is very similar to that in cirrhosis. 

Microscopically it is seen that the entire tissue is infiltrated 
by the cancer cells. Surrounding these collections of cells 
are bands of connective tissue, and lying in between the two 
is a narrow zone composed of atrophic hver-cells that have 
been pushed aside by the neoplastic cells. The capillaries are 
found to be filled with cancer cells and the infiltration may 
become so great as to obliterate blood-vessels and bile-ducts 
and completely destroy the function of the liver. 

A third variety of primary cancer is the interlobular form. 
In this the carcinoma has extended along the distribution 
of the portal vein and invades but slightly the neighboring 
tissue. The fiver appears to the naked eye very much like 
an atrophic cirrhosis, having the same irregular surface. 
Is frequently spoken of as cirrhotic cancer. 

Secondary cancer is frequently found in cases of primary 
growths of the stomach, intestine, pancreas, mammary 
gland, and uterus. Occurs in connection with those organs 
whose venous blood empties into the portal system. It 
generally appears in the form of numerous nodules dissemi- 
nated through the organ. The nodes vary greatly in size, the 
large ones frequently showing a depressed, umbilicated center, 
the result of necrosis and softening with absorption. These 
secondary growths are, as a rule, quite well circumscribed. 
The cells that compose them resemble more or less closely 
those of the original neoplasm. ^Masses of these cells gain en- 
trance into the circulation as emboli, and wherever they lodge 
they undergo division and give rise to new tumors. 

Cysts of the liver are unusual. Are usually formed by 
the dilation of a bile-duct, but may be due to an obstruc- 
tion of the lymphatics. 

Echinococcus cysts are comparatively common. Are 
caused by the Ta?nia echinococcus, a parasite of the dog. 
The cysts may be either unilocular or multilocular; in the 
24 



370 A MANUAL OF PATHOLOGY 

latter case they may occupy the greater part of the organ. 
The wall of the cyst consists of an outer connective -tissue 
layer and an inner cellular layer from which secondary 
cysts may grow. 

These cysts by their pressure cause atrophy of the liver 
substance, icterus, and ascites. They may rupture into the 
abdomen, neighboring organs, or at times into the vena cava 
with general distribution. If bacteria gain entrance, the 
cysts may become transformed into an abscess. Occasionally 
the contents of the cysts may be absorbed and replaced by 
cicatricial tissue. 

Parasites. — ^The most common and important is the larva 
of the TcTnia echinococcus, which gives rise to the cysts above 
described. Amcrba coli in cases of tropical dysentery gains 
entrance and frequently gives rise to abscess formation. 
Coccidiiim ovijorme, a common protozoa in lower animals, 
has been found in man. It forms growths that resemble 
somewhat adenomata. The Distomiim hepaticum, lancco- 
latimt, in the bile-ducts, and the D. Jiematobium, in the portal 
vein, are sometimes seen. 

DISEASES OF THE GALL-BLADDER AND BILE-DUCTS 

Angiocholitis or cholangitis, inflammation of the bile- 
ducts, is generally found in the common duct. It may, 
however, extend throughout the smaller ducts and capillaries. 
Is commonly secondary to inflammatory conditions in the 
stomach or duodenum. May be due to bacteria entering 
from the intestine or to irritation by the presence of a gall- 
stone. The catarrhal form is characterized by the |)resence 
of mucus, the purulent \'ariety by the presence of ])us. 

The mucosa becomes reddened, swollen, edematous, and 
covered by mucus. If the inflammation becomes more severe, 
pus is secreted and perforation with abscess formation may 
occur. As a result of the swelling the outflow of bile is 
hindered and icterus follows. The duct above becomes 
dilated and frequently cystic; gall-stones may also form on 
account of the stasis. 

If the swelhng subsides bile begins to circulate and the 



DISEASES OF THE DIGESTIVE SYSTEM 371 

symptoms cease. If there has been permanent obstruction 
to the duct by connective-tissue formation, secondary changes 
within the hver take place, such as bihary cirrhosis. 

Cholecystitis is an inflammation of the gall-bladder. It 
is commonly due to gall-stones within, but maybe due to in- 
fection from without. When gall-stones are present the 
cystic duct is obstructed, the bile is unable to escape, and the 
gall-bladder becomes distended. The coloring-matter of the 
bile may eventually be absorbed and the bladder be filled 
with a colorless fluid. From the pressure of gall-stones ulcers 
may form and perforation into the peritoneal cavity, into the 
intestine, or through the abdominal wall occur. 

When the inflammation is infectious, it may become 
purulent and the bladder be distended with pus, a condition 
called empyema of the gall-bladder. 

The wall of the bladder is generally thickened and the 
mucosa ulcerated. 

Stenosis of the bile-ducts is generally due to obstruction 
in acute inflammation by the thickening of the mucous mem- 
brane and the presence of mucus. In chronic inflammation 
there may be an overgrowth of connective tissue. Foreign 
bodies within or neoplasm from without may press upon the 
ducts and obstruct them. According to the location of the 
stenosis difl^erent conditions result. If the cystic duct be 
closed, the Hver tissue is unaffected, but the bile is unable to 
escape from the gah-bladder, which becomes much distended. 
If the hepatic duct is obstructed, all the smaller ducts and 
capillaries above become dilated by the retained bile, and in- 
fection frequently occurs, giving rise to a suppurative cholangi- 
tis. Obstruction of the common duct will give rise to the dila- 
tation of both gall-bladder and biliary ducts. As a result the 
liver becomes enlarged and deeply stained by bile-pigments. 
The cells in the outer zone of the acini contain pigment 
granules, and there is frequently an overgrowth of fibrous tis- 
sue along the ducts. Areas of necrosis may also be present. 

Cholelithiasis. — Gall-stones, calculi of the gall-bladder, 
are soHd masses resulting from the precipitation of various 
substances from the bile. They are most frequently found 



372 



A MANUAL OF PATHOLOGY 



late in life and most commonly in women. It would seem 
that they form about a nucleus composed of desquamated 
epitheHum, bacteria, thickened mucus, or a foreign body 
from outside. Upon this body is deposited a layer of bihary 
salts; more layers are built up until a fairly large stone is 
found. This process is hastened if there is stasis and some 
decomposition of the bile. Instead of one large stone several 
may form, or there may be thousands, Hke grains of sand. 



#• 





• 



Fig. 144. — Types of Gall-stones. (From a photograph in the collection 
of Dr. Jepson, Sioux City, la.) 
a caused complete intestinal obstruction for eight days; h and c were 
removed from the gall-bladder and show points of attrition; d, solitary 
stone removed from gall-bladder; no point of attrition; r, gall-stone of 
irregular shape, due to compression or moulding; /, solitary stone from 
common duct. 



The shape depends upon the number present. If single, 
it may be round or ovoid. Usually the sides are flattened by 
mutual pressure, giving an irregular crystal-hke form. The 
color of the stones varies, according to their composition, 
from light yellow, through various shades of brown to black. 

They are generally formed in the gall-bladder, but may 
originate in the larger ducts. 

The common variety is yellowish or brownish and is com- 
posed mainly of cholesterin and bihrubin in combination. 



DISEASES OF THE DIGESTIVE SYSTEM 373 

Other forms of calculi are made up of cholesterin, of 
bilirubin, and of calcuim carbonate. 

Although bihary calculi may exist for years without giving 
rise to any disturbances, they frequently cause more or less 
serious lesions. The gall-bladder generally shows some 
catarrhal inflammation. The walls may exhibit slight or 
marked changes, they may be much thickened, ulcerated, or 
pouched. The calculi may escape from the gall-bladder as 
a result of ulceration with perforation. Is fairly common 
in choleHthiasis and most frequently perforate externally. 

The most severe symptoms result when one of the calculi 
escapes from the gall-bladder into the cystic and common 
bile-ducts. This gives rise to biliary colic, a very severe form 
of pain which is associated with symptoms of collapse. If 
the stone is small, it can pass on through the ducts into 
the intestine. It may, however, become lodged in the lower 
part of the common duct, usually just above the outlet into 
the duodenal papilla. Following the blocking of the common 
duct there is retention of bile, which if long-continued gives 
rise to marked jaundice and lesions within the liver. The 
flow of bile may be resumed by dislodgment of the stone or 
by the estabhshment of a passage around the foreign body. 

An accompanying symptom of biliary coHc is an inter- 
mittent fever in which the temperature may go up to 104° or 
105° F. at the onset. It then subsides and reoccurs. 

Tumors of the gall-bladder are quite uncommon. About 
the only form is a primary carcinoma arising from the mucous 
glands. This growth seems to be quite frequently associated 
with gall-stones, which may be causative or merely the re- 
sults of the stagnation of the bile. The liver is soon secondar- 
ily involved. 

Jaundice or icterus is a staining of the tissues by biliary 
pigments that have been conveyed by the blood-stream. It 
is a symptom common to most diseases of the liver. There 
were formerly thought to be two forms of jaundice, the 
obstructive or he|)atogenous and the non-obstructive or 
hematogenous. The latter variety probabh' docs not really 
exist, all icterus being due to biliary coloring-matter. There 



374 A MANUAL OF PATHOLOGY 

are, however, cases in which no mechanical obstruction can 
be observed, cither by absence of bile in the feces or by lesions 
in the liver. This discoloration is seen in some infectious 
diseases and after experiments in which various substances 
have been injected into the blood. 

Catarrhal jaundice resulting from obstruction to the duct 
by an inflammation of its mucous membrane is the common- 
est form. Any obstruction will, however, cause it. Micro- 
scopically it is seen that the bihary capillaries are distended 
and the hver cells contain more or less pigment. The bile 
escapes from its normal channels, is taken up by the lymph- 
atics, from which it passes into the circulation and thence to 
the tissues throughout the body. The secretions and ex- 
udations of the body may be distinctly tinged. The tissue 
first stained is the intima of the blood-vessels; finally the skin 
and the sclera, where it is seen most characteristically. Ac- 
cording to the duration, the color will vary from a light yellow 
to a dark bronze-green; the longer continued, the darker the 
color. If httle or no bile escapes, the feces will usually be 
very light in color, clay-like. 

The retention of bile within the body is generally ac- 
companied by quite marked disturbances, particularly of the 
nerv'ous system. As the flow of bile is re-established the 
discoloration gradually disappears. 

PANCREAS 

Malformations are unusual, except that the pancreas 
may frequently be composed of separated segments. Frag- 
ments of pancreatic tissue are sometimes found in the omen- 
tum, the walls of the intestine or of the stomach. Varia- 
tions of the ducts are very common. The duct of Wirsung 
may be double, its relation to the duct of Santorini may vary 
greatly. Both ducts may open separately into the duodenum. 
Usually the duct of Wirsung and the common bile-duct open 
into the diverticulum of Vater. 

Active hyperemia is present during digestion and as a 
stage in inflammation. Passive hyperemia occurs when there 
is some obstruction to the portal circulation. Is common 



DISEASES OF THE DIGESTIVE SYSTEM 375 

in alcoholics and may lead to the formation of connective 
tissue. 

Acute hemorrhagic pancreatitis is an uncommon con- 
dition of unsettled origin. It occurs in men rather than in 



« <*• M^ • V^^ /•} '"'•* Ce/ •<»-.. .^- 










.i'- ^t^ 







.v.„^-'-u^^V 









■^\ 






:^^ 



Fig. 145. — Chronic Interstitial Pancreatitis Following Duct 
Obstruction, showing Islands of Langerhans unchanged though 
Embedded in Sclerotic Tissue (Opie). 

women and seems to be associated in many cases with chole- 
lithiasis. By obstruction of the diverticulum of Vater bile 
may be forced up into the duct of the pancreas and give 



376 A MANUAL OF PATHOLOGY 

rise to hemorrhagic pancreatitis. Various irritating sub- 
stances when injected into the duct of Wirsung have given 
rise to a similar condition. The ereater part of the pan- 
creas IS generally involved and death frcquentlv comes on 
quite suddenly. Microscopicallv there is found extensive 
necrosis of the parenchyma and of the interstitial tissue as 
well. The stroma is the seat of a marked round-cell in- 




Fig. 146.— Chronic Interstitial Pancreatitis of Interacinar Type 

SHOWING THE LnVASION OF AN ISLAND OF LaNGERHANS BY THE IN- 
FLAMMATORY Process (Opie). 

filtration and the fat frequently contains areas of necrosis. 
The epithehum is the seat of fatty degeneration and may be 
no longer recognizable. 

Blood-vessels may be eroded and hemorrhage occur. Is 
impossible to sharply separate pancreatic hemorrhage and 
hemorrhagic pancreatitis. 



DISEASES OF THE DIGESTIVE SYSTEM 377 

Purulent pancreatitis may originate as such primarily or 
it may follow the hemorrhagic form. There may be a diffuse 
leukocytic infiltration or a formation of miliary foci of sup- 
puration with here and there distinct abscesses. The in- 
fection may be due to the extension of inflammatory pro- 
cesses of a neighboring organ. 

Gangrenous pancreatitis in many cases is a ^p gupl of 
t he acute hemorrhagic or it may follow the purulent varie ty. 
The gland is swollen, dark red, and soft; and may be con- 
verted into a dark, slate-colored, bad smelling mass. The 
entire gland may at last be changed into a large necrotic 
mass. Accompanying these changes numerous scattered 
foci of fat necrosis occur. 

Chronic or interstitial pancreatitis is characterised by 
an overgrowth of fibrous tissue with more or less atrophy of the 
parenchyma. The connectiye tissue may be increased, either 
interlobular or interacinar. In the interlobular variety the 
islands of Langerhans are unchanged, while in the interacinar 
form the fibrous tissue surrounds and invades them. Cir- 
rhosis is frequently found in alcoholics. 

Syphilitic pancreatitis is not unusual in congenital 
cases. There is diffuse prohferation of fibrous tissue be- 
tween the lobules and the acini. The cells also atrophy and 
disappear and the blood-vessels are the seat of a periarteritis. 
The islands of Langerhans are not affected. Gumma is 
rare, a few cases only having been reported. 

Tuberculosis is infrequently met with, but may occur in 
the miliary form or, what is more rare, as a large caseous mass. 

Atrophy of the pancreas is frequently found in old age, 
in local disturbances of the circulation, cachexia diabetes, 
and emaciation. 

Hanseman's form of atrophy is consequent upon chronic 
inflammation. The organ is diminished in size and flattened, 
the fibrous tissue is usually adherent to adjacent organs, 
the epithelial elements are atrophic and are in part replaced 
by connectiye tissue. Hanseman thought that this form of 
atrophy was always present in cases of diabetes. Opie has 
found, howeyer, that it is only in the interacinar form in 



37^ A MANUAL OF PATHOLOGY 

which there is a hyahne degeneration of the islands of Langer- 
hans that diabetes occurs. 

Fatty infiltration is not infrequently found accompany- 
ing various of the infectious fevers. The fat is deposited 
chiefly in the interlobular connective tissue and causes a 
secondary atrophy of the parenchvmatous cells which 
may also contain some fat. The organ may be a trifle en- 
larged, soft, and grayish in color. 

Fatty metamorphosis occurs as a result of severe infection, 
as in chronic phos}jhorous poisoning. The organ is soft and 
cloudy white. 

Fat necrosis is a peculiar form of degeneration taking 
place in the falty tissues of the ])ancreas and omentum. It 
appears as smaU, opaque, white areas in the immediate 
neighborhood of the pancreas or scattered throughout the 
organ itself. Several areas may become confluent and in- 
volve a large portion of the pancreas. The necrotic areas 
may be more widely disseminated, involving the omentum 
and the subperitoneal and the retroperitoneal tissue. They 
are opaque, whitish or yellowish, are sharjjly defined from 
the normal fat, and are generally surrounded by a narrow 
hemorrhagic zone. 

IVIicroscopically the afi"ected tissues show absence of nuclei 
with presence of fat crystals and lime salts. 

This form of necrosis is due to obstruction of the outflow 
of the secretion, or to the escape of the })ancreatic juice into 
the peritoneal cavity. A fat-splitting ferment is present and 
it breaks up the fat into glycerin and a fatty acid. The 
acids are deposited as needle-like crystals with the broken- 
down cell. The glycerin is absorbed and the acids unite 
with calcium to form calcium salts, which give a gritty feel 
when the tissue is cut. 

In the majority of cases fat necrosis is associated with 
either hemorrhagic or gangrenous pancreatitis. 

Amyloid degeneration is found in cases of general 
amyloid disease, occurring either in spots or in streaks. 

Hyaline degeneration is met with quite frequently. It 
involves the islands of Langerhans as weU as the parenchy- 



DISEASES OF THE DIGESTIVE SYSTEM 379 

matous tissue. The affected portions stain with eosin and 
picric acid, but do not give the amyloid reaction. 

This lesion is thought to have a distinct relation to diabetes 
mellitus. The islands of Langerhans are most numerous in 
the tail of the pancreas. In certain cases of diabetes there 
has been a marked absence of these bodies, due to hyaline 
change. The parenchymatous cells in such cases may or 
may not be involved. It would appear that as long as the 
islands remain unaffected diabetes will not be present, no 
matter how seriously involved the parenchyma is. These 
peculiar bodies of Langerhans apparently exert a distinct in- 
fluence upon the metabohsm of sugar. 

As diabetes can be caused by lesions of the fourth ventricle 
it is evident that all cases cannot depend upon pancreatic 
lesions, but there is a distinct association in many cases. 

Pigmentation may be due to hemorrhage, to atrophy, or 
old age. The epithelial cells contain brownish or yellowish 
granules that do not give an iron reaction. 

Tumors. — Sarcoma is rare, but the round-cell and angio- 
matous forms have been described. They may occur as a 
part of a secondary sarcomatosis. 

Carcinoma may occur primarily or after a similar growth 
in the stomach, duodenum, or gall-bladder. The primary 
form is found in the head of the gland and is most commonly 
scirrhus. It soon spreads and forms a large mass involving 
the greater part of the pancreas and the adjacent tissues. As 
it grows it may obstruct the bile-ducts, giving rise to icterus, or 
by pressure upon the duct of Wirsung set up a chronic 
interstitial pancreatitis sometimes accompanied by diabetes. 

The growths generally originate from the cells of the acini 
and give an adenomatous structure to the tissue. They may 
arise from the cylindric epithelium of the ducts and form a 
scirrhous mass. 

Obstruction of the pancreatic duct may cause it to become 
greatly dilated, so much so as to cause actual cyst formation. 
The contents are usually clear, but by infection may become 
purulent. Occasionally small cysts may be scattered through 
the organ. 



380 A MANUAL OF PATHOLOGY 

Calculi in the duct are sometimes found. They may be 
a cause of obstruction. 

DISEASES OF THE PERITONEUM 

Malformations are occasionally met with. The omen- 
tum may be very small or unduly long. The mesentery may 
be vcrv long, gi\ing rise to enteroptosis. IMay allow hernias. 

Circulatory Disturbances. — Active hyperemia, either 
localized or diffuse, is present during the early stage of in- 
flammation, and is also met with in relation to tubercles and 
neoplasms. Passive hyperemia follows obstruction to the 
portal circulation. The veins may become much distended 
and tortuous and small hemorrhages into the subperitoneal 
tissue may be jjrcsent. 

Hemorrhagic beneath the peritoneum in the form of petechiie 
and irregular streaks is found in chronic j^assive congestion, 
in asphyxia, in phosphorous poisoning, and in some infections. 

Hemorrhage into the peritoneal cavity results from rup- 
ture of a blood-vessel. When as a consequence of trauma- 
tism any of the internal viscera, as spleen or liver, rupture, 
blood will be present. Is also found in cases of rupture of 
abdominal aneurysms, and of extra-uterine pregnancy, and 
from typhoid or other perforations. 

The blood collects in the dependent portion of the abdo- 
men and may coagulate or remain fluid. If the patient re- 
covers the blood may be absorbed without any permanent 
changes, although adhesions sometimes form. 

Ascites or a collection of serous fluid within the peritoneal 
cavity is frequently seen. It may be due to obstruction of 
the pqrUl_cJTCulat ion ^especially in atrophic .cirrhosis of the 
Hver or as a part of a general dropsical condition in cardiac 
and renaTcTiscasc. 

It is also found in some local diseases of the peritoneum, 
as tuberculosis, etc. 

TTie ascitic fluid is generally clear, straw-colored, with a 
small amount of albumin, which rarely coagulates spontane- 
ously. The amount may vary from a few cubic centimeters 
to several liters and may become so great as to cause marked 



DISEASES OF THE DIGESTIVE SYSTEM 381 

inconvenience by distending the abdominal cavity and by 
pushing the diaphragm upward. This latter may cause 
extreme dyspnea. If the fluid is removed, it frequently 
collects again and again. If adhesions have formed, there 
may be locahzed collections of fluid. 

If there has been obstruction to the thoracic duct, the 
ascitic fluid is frequently milky in character, due to the 
presence of chyle {chylous ascites). This fluid contains fat 
droplets as well as the red and white cells that are ordinarily 
present. 

Sometimes there may be a collection of fluid between the 
layers of the omentum. 

When the ascites has existed for a long time there is nearly 
always a secondary chronic inflammation of the peritoneum 
with thickening. 

Peritonitis, inflammation of the peritoneum, may be 
primary or secondary. This serous membrane covers such 
a large surface and so readily absorbs fluids that infection 
may take place with comparative ease. 

Primary or idiopathic acute peritonitis arises through the 
infecting agent being carried by the blood from a pyogenic 
focus in some distant part of the body. 

Secondary acute peritonitis is the more common form. It 
follows local injury to the peritoneum, as a result of injury 
or disease, the infecting agent being carried generally by the 
lymphatics. 

Peritonitis is brought about by infectious inflammations 
of neighboring tissues, particularly in septic conditions of the 
female genital organs, by perforations of the stomach or in- 
testines, by appendicitis, by strangulation of the bowels, etc. 

According to the extent of the lesion the peritonitis may 
be localized or general. The severity of the disease also 
differs greatly. 

The membrane at the point of infection is at first hypcremic, 
is dull, and a serous or serofibrinous exudation soon appears. 
This rapidl)' becomes purulent or may have been so from the 
beginning. If the process has not been a very rapid one the 
affected area will be covered bv a thick whitish or creamv 



382 A MANUAL OF PATHOLOGY 

layer of fibrin. As the exudate increases in quantity it 
collects in localized pockets among the coils of intestine. 
The fibrin may undergo organization, adhesions form, and the 
purulent matter be surrounded and walled off. It may be 
absorbed, infiltrated with lime salts, or replaced by fibrous 
tissue. The pus may burrow and empty either externally 
or into some hollow organ. If the adhesions have not been 
sufficiently dense, the abscess may break through and infect 
the greater part of the peritoneum. In such a severe form 
the serous membrane becomes infiltrated and partially dis- 
organized. 

Localized peritonitis is not usually fatal, but in the general 
form recovery is rare. When peritonitis sul^sides and the 
individual fives, adhesions of varying extent remain. These 
eventually become transformed into dense fibrous bands that 
may cause veiy severe trouble by binding the coils of in- 
testine together or by so compressing them that the bowel 
becomes more or less obstructed. 

As a result of the acute inflammation the peristaltic action 
of the intestines is at first stopped by spasmodic contractions. 
In a very short time the muscle fibers become paralyzed 
and there is then almost complete cessation of motion. 
General septicemia may follow the peritonitis. 

In the new-bom peritonitis generally follows septic in- 
fection of the umbilical cord. 

Chronic pcrilonilis may follow in the course of acute peri- 
tonitis, particularly if it were locafized. When encapsulated 
collections of pus have failed to be absorbed the peritoneum 
adjacent shows marked chronic thickening. Local thicken- 
ings may also be due to chronic disease of the underlying 
organ. This is particularly the case at times on the fiver 
and spleen. The membrane becomes very thick, white and 
smooth, and resembles icing of a cake, the so-called '' Zucker- 
guss" organs. Chronic peritonitis is particularly common in 
the neighborhood of the female genitalia; all of which, uterus, 
tubes, and o\aries, may be united by dense bands of connec- 
tive tissue. Is also always present in tuberculosis of the 
peritoneum. 



DISEASES OF THE DIGESTIVE SYSTEM 383 

Tuberculosis of the peritoneum is seldom primary, but 
is commonly found as a secondary lesion in similar disease 
of the intestine or mesenteric lymph-nodes. The condition 
may be local, being limited to the peritoneal surface of the 
intestine overlying tubercular ulcers; or it may be widely 
disseminated as a general miliary involvement. The lesions 
may coalesce and form large caseous areas or there may be 
extensive connective-tissue formation with adhesions caus- 
ing the intestines to be bound together in one dense mass. 
Occasionally there may be considerable serous exudate 
present; if the exudate is purulent it generally indicates that 
there has been a secondary infection by pus-producing or- 
ganisms. The exudate may at times be completely absorbed 
or remain as sacculated collections. The tubercles may 
heal by granulation and cicatrization and the individual get 
well. 

The mesenteric lymph-nodes are generally enlarged and 
caseous. 

Tumors. — Primary tumors are unusual, new growths 
being generally metastatic or the result of direct extension. 
Fibroma and lipoma are sometimes seen. Sarcoma is rare. 
Emlotheliomata are quite frequently found. As a rule, there 
is not a localized growth, but is distributed throughout the 
peritoneum, giving somewhat the appearance of tuberculosis. 
The omentum is probably the scat of the primary growth. 

Carcinoma is nearly always secondary, but it is thought that 
])rimary carcinoma might arise from fragments of epithelial 
tissues, from fetal remnants, or from portions of intestine 
pinched off in fetal life. There is usually a general dis- 
tribution of tumor nodes of all sizes over the greater part of 
the peritoneum. When the nodules are widely distributed 
the condition is known as ''carcinomatosis.''^ There is 
always some inflammatory reaction, so adhesions are quite 
common. The carcinoma may extend from various abdomi- 
nal organs, as the uterus, tubes and ovaries, and intestines. 
A gelatinous or colloid cancer of the stomach or intestine 
is usually soon followed by a similar growth involving the 
peritoneum. Such a tumor contains large and small masses 



384 A MANUAL OF PATHOLOGY 

of clear colloid material resulting from degeneration of the 
cells. 

Cysts are sometimes encountered, the usual form being due 
to a dilatation of lymph-vessels. 

Parasites are rare, but echinococcus cysts have been 
found as well as tilaria and actinomvces. 



1 



CHAPTER XXII 
DISEASES OF THE URINARY ORGANS 

THE KIDNEYS 

Malformations. — Rarely both kidneys may be absent, 
but the fetus is incapable of living. Absence of one kidney 
is more common and is not incompatible with life. The left 
organ is usually wanting and the right undergoes com- 
pensatory hypertrophy so as to perform its extra work. 

Atrophy of a kidney is not infrequent, it being represented 
by a small body composed of connective tissue with very 
little glandular structure. A third kidney has been seen in 
a few cases. The lobulation of the kidneys during fetal life 
usually disappears by the tenth year, but it may persist till 
late Hfe. 

Horseshoe kidney is the result of the fusion of the two kid- 
neys at either their upper or lower ends. The band of union 
may be purely fibrous or of renal tissue. The ureters, from 
two to four, arise from an anterior pelvis. The vessels are 
usually more numerous than normal and are generally 
anomalous. 

One of the kidneys, usually the right, may become much 
displaced downward and hang from a much stretched peri- 
toneal covering. Is the ''floating kidney" and can give 
rise to many symptoms. The left may be displaced congeni- 
tally. The relaxation of the support of the right kidney 
may be due to disease or dis])lacement of the liver, to tight 
lacing, or to a dragging exerted by the stomach or transverse 
colon. The perineal fat decreases, the peritoneal covering 
stretches, and the kidney is easi^ly moved. The nerves and 
vessels and the ureters are put in a state of tension and severe 
symptoms arise. If the pedicle becomes twisted the circula- 
rs 385 



386 A MANUAL OF PATHOLOGY 

tion may suffer and by obstruction to the ureter urine collect 
and give rise to a hydronephrosis. 

Circulatory Disturbances. — Anemia of the kidneys is 
present in general anemia ; or it may be due to gradual ob- 
struction of the arteries, either by disease or by pressure from 
without. If the obstruction has been sudden, necrosis is 
usually present. The organ is small and light in color. If 
the anemia continues, there is interference with the secretion 
of urine and atrophy may ensue. Fatty degeneration appears 
first in the glomeruh but soon involves the parenchyma. 

Acute hyperemia is generally a stage of acute inflammation 
in infectious conditions. Numerous irritating bodies that 
are excreted through the kidneys may give rise to the 
hyperemia. Such are certain poisons, as cantharides, car- 
bolic acid, toxins of infectious conditions, as scarlet fever, 
those present in cases of extensive superficial burns. The 
kidneys are slightly enlarged, dark red in color, and soft. 
The capsule strips easily and on section much blood escapes. 
In the cortex are seen numerous minute red spots, the 
]\Ialpighian bodies, and the congestion exists throughout. 
The epithelium usually shows some cloudy swelling. The 
urine may contain a few erythrocytes, a trace of albumin, and 
cyhndroids. 

Passive hyperemia may be due to cardiac or pulmonary 
disease, to thrombosis of the inferior vena cava or of the renal 
veins, or to pressure upon these veins from w^ithout. Some- 
times there may be an acute passive stasis, the organ becomes 
much distended and death may result. Ordinarily the kid- 
ney is enlarged, dark in color, and soft, with a capsule that 
strips readily. The stellate veins are prominent, blood drips 
from the cut surface, the Malpighian bodies are enlarged and 
the bases of the pyramids are markedly congested. If the 
hyperemia is of long standing there is always more or less 
hyperplasia of the connective tissue. So much so that the 
organ, although enlarged, may be hard and dark in color, 
owing to the deposition of pigment; is known as cyanotic 
induration. The capsule is usually somewhat adherent and 
the surface of the organ irregular. The epithelial cells show 
some fatty degeneration and atrophy. 



DISEASES OF THE URINARY ORGANS 387 

The amount of urine is diminished and contains varying 
numbers of red and white blood-corpuscles, some albumin, 
and a few hyaline or granular tube casts. 

Hemorrhage in the form of punctate collections may 
occur in severe acute or passive hyperemia. The blood 
will be found within the interstitial tissues, in the tubules, 
or in Bowman's capsule; it may escape by actual rupture or 
by diapedesis. Large hemorrhages usually occur only as a 
result of trauma, but may be due to infarction. The urine 
will contain blood either as free corpuscles or as the so-called 
blood-cast. 

Arteriosclerosis.— The kidney may show most marked 
sclerotic changes, such as are found elsewhere in the body. 
All the vessels are not uniformly involved, so there are irregu- 
lar appearances. The \'cssels become gradually occluded by 
a thickening of the walls with a decrease in the lumen. The 
areas supplied by such vessels undergo atrophy, degeneration, 
and frequently become infiltrated with hmc salts. Fibrous 
connective tissue forms to some extent, and as this contracts 
it compresses the urinary tubules. Excretion continues, the 
tubules dilate, and small retention cysts form both on the 
surface and in the kidney tissue. The kidney is smaller than 
normal, firm, and its surface shows depressed areas repre- 
senting the atrophic portions, at which points the capsule 
may strip with difficuhy. 

Microscopically the alterations in the blood-vessels are 
seen and the glomeruli in many instances are surrounded by 
greatly thickened capsules which may contract until the capil- 
lary tufts have been reduced to small fibrous masses. If 
there is much connective tissue present it indicates that there 
has been a chronic inflammation of the organ, an interstitial 
nephritis. This is not uncommon, as the same etiologic 
factors will bring about both the arteriosclerotic and the 
interstitial changes. Is caused by syphilis, chronic lead 
poisoning, gout, and old age. 

In this form the urine is practically unchanged. 

Infarcts of the kidney are common, as the arteries have 
practically no anastomoses with each other. In the anemic 



388 A MANUAL OF PATHOLOGY 

infarct the appearance varies according to the age of the 
lesion. When recent, there is a pale, circumscribed ele- 
vation on the surface of the kidney, surrounded by a narrow 
zone of hemorrhage. If old and connective-tissue forma- 
tion has occurred, there is a depressed area. On section it is 
seen that the involved portion is conical in shape with the 
apex directed toward the hilum. The epithelium becomes 
cloudy and soon degenerates. This area becomes transformed 
into scar tissue in the course of time. In hemorrhagic in- 
farcts the process is the same except that the area has be- 
come filled with blood which gives it its dark appearance. 

Thrombosis of the larger renal veins may give rise to con- 
gestion and edema with degeneration and necrosis of the 
area involved. 

Embolism is not uncommon, and on account of the lack 
of anastomoses of the renal arteries usually results in in- 
farction. Embolism may be single or multiple, and if 
bacteria are present suppurative processes are present in 
addition to the already mentioned lesions. 

Degenerations. — Parenchymatous degeneration or cloudy 
swelling is a condition in which the secreting epithehum is 
involved. It occurs in diphtheria, scarlet fever, and in most 
of the infectious diseases. 

If the conditions that bring about this change persist, 
the cloudy swelling is very apt to pass over into the acute 
parenchymatous nephritis. In cloudy swelling the kidney 
is larger than normal, somewhat softer, and yellowish or pale 
gray. The cut surface shows the Malpighian bodies as 
small red dots and the pyramids are often markedly con- 
gested. The cells in the tubules are swollen and cloudy on 
account of the presence of numerous minute granules, and 
the nuclei are hidden. 'The kidney may return to the nor- 
mal or else acute B right's disease or fatty degeneration may 
ensue. 

Fatty degeneration may follow cloudy swelhng or arise as 
a consequence of various diseases, as pernicious anemia or 
tuberculosis. As fat is never normally present in renal 
epithehum, its occurrence is always pathologic and is in- 



DISEASES OF THE URINARY ORGANS 



389 



dicative of a degenerative process. It is due to the lack of 
nutrition, and at times is added a toxic effect of some sub- 
stance in the circulating blood. 

The kidney is about the normal size or smaller, is soft, 
the cortex is not thinned, and the organ is uniformly yellow- 
ish unless there is much congestion present. The fat may 
be diffusely present, or, what is quite common, occur in 







Fig. 147. — Cloudy Swelling of the Kidney Epithelium. X 800 

(Zieglcr). 

a, Normal epithelium; b, beginning cloudy swelling; c, marked degeneration; 

d, desquamated degenerated epithelium. 



streaks along the collecting tubules of the pyramids. It is 
also seen as minute yellow points. The cells contain granules 
or oil drops of varying size. 

Amyloid degeneration of the kidney follows the same 
causes as bring it about in the liver and spleen, such as the 
long-continued suppuration in bone diseases, in tuberculosis, 
and in syphilis. The kidney is usually much enlarged, 



390 A MANUAL OF PATHOLOGY 

harder than normal, and grayish or shghtly yellowish in 
color. If the process is not general the organ will appear 
mottled, areas of fatty degeneration being present. This de- 
generation begins, as a rule, in the capillaries of the glomeruH, 
from which it extends to the neighboring connective tissue, 
but not at the epithelium. If the degeneration has not been 
extensive fatty changes are uncommon, as the blood-supply 
may still be sufficient for the nutrition of the cpitheHum. 
Microscopically the glomeruh are seen to consist of a homo- 
geneous and translucent mass in which the capillaries can- 
not be distinguished. The capsule of Bowman may also be 
involved. As the circulation is interfered with the organ 
becomes anemic, and fatty degeneration of the epitheKum 
occurs. The amyloid areas give a mahogany brown color on 
the addition of Lugol's iodin solution. The urine is dimin- 
ished and contains albumin and hyaline casts occasionally. 

Glycogen is found in the epithelium in the loops of Henle 
in cases of diabetes. The cells, instead of being granular, 
are homogeneous and give the dark brown color with iodin 
if the tissue has not been put in watery fluids. Glycogen 
differs from amyloid in being soluble in water. 

Calcification may take place in old degenerated areas in the 
connective tissue or in the necrotic epithehal cells. Under 
this heading come the so-called "calcareous infarcts," in 
which various salts are deposited, particularly in the straight 
collecting tubules. They may be composed of urates, and 
the presence of such infarcts has been thought to indicate 
that a new-born child has breathed. 

Nephritis, inflammation of the kidney, or Bright's disease 
is brought about by many conditions, all of which in some 
way produce an irritation of the kidney by means of the cir- 
culation. It follows in the course of poisoning by certain 
chemicals, such as arsenic, mercury, phosphorus, cantharides, 
and turpentine; especially in the course of the acute infectious 
diseases, and also in certain chronic infections, as syphilis 
and tuberculosis. Nephritis may be acute or chronic and 
parenchymatous or interstitial, according to whether the 
changes in the epithelium or in the connective tissue pre- 



DISEASES OF THE URINARY ORGANS 



391 



dominate. If both are more or less equally involved the 
term diffuse is applied. 

Acute parenchymatous nephritis is found in the course 
of the acute infectious fevers, particularly in diphtheria, 
scarlet fever, and smallpox. The kidneys are usually en- 
larged, red in color, soft, and edematous. The capsule strips 




Fig. 148.— Acute Parenchymatous Nephritis (Catarrhal) (McFar- 

land). 

a Tubule denuded of a large part of its epithelium; h, cells in a condition 

of degeneration; c, mass of desquamated cells in a tubule. 



easily. On section bloody fluid escapes. The cortex is 
thicker than normal and is much paler than the medulla, 
which is dark red. The anemia of the cortex is due to the 
swelling of the cells which compress the capillaries. The 



39^ 



A MANUAL OF PATHOLOGY 



epithelium is swollen, cloudy, and in many places has be- 
come desquamated. This is most marked in the con- 
voluted tubules. 

In some cases, particularly in scarlet fever, the changes 
may be most noticeable in the glomeruh, the glomerulo- 







Fig. 149. — Chronic Glomerulonephritis. X 320 (Diirck). 
The capsule fibrillated and thick (5); septa extend inward between the 
desquamated epithelial cells (3) and leukocytes (4); 2, innermost layer 
of connective tissue surrounding the greatly diminished tuft (i), which is 
covered with epithelial cells, the lumen containing leukocytes. 

nephritis. In this varietv the capsular space contains des- 
quamated epithelium from the capsule, red and white blood- 
cells, granular matter, and an albuminous exudate. The 
cells may show fatty degeneration. The erythrocytes may 
be sufficiently numerous to form blood-casts. 



DISEASES OF THE URINARY ORGANS 



393 



The glomeruli are seldom alone involved, the more com- 
mon condition being a combination with changes within the 
tubules. 

Ordinarily either of the two preceding varieties terminate 
in the acute diffuse nephritis, a form in which there are ex- 
udative or proliferative changes in the interstitial stroma. 




Fig. 150. — Chronic Parenchymatous Nephritis (Kaufmann). 

a, Convoluted tubules with cloudy swelling of the e{;ithelium; b, glom- 
eruli, more or less degenerated; c, atrophic tubules; d, sclerotic interstitial 
tissue; e, round-cell infiltration; /, blood-vessel; ^, tube-casts in tubules. 



The kidney is larger than normal and may be either dark 
and congested or pale on account of parenchymatous changes. 
The cortex is much increased in thickness and shows areas of 
congestion. The capsule strips easily. The microscopic 
changes are many. The epithelial cells may be cloudy or 
swollen, show fatty degeneration, or at times be necrotic. 
Accompanying these changes there may be a well-marked 



394 A MANUAL OF PATHOLOGY 

round-cell infiltration in the connective tissue. There may 
also be small areas of hemorrhage into the tubules or the 
capsule of Bowman. 

The urine is decreased in amount and at times suppressed, 
has a high specific gravity, is dark in color and contains 
many casts. Microscopically are seen red and white blood- 
cells, desquamated epithelium, and tube casts, particularly 
the epithelial and granular forms. 

Chronic parenchymatous nephritis may be the result of 
numerous attacks of acute nephritis, or it may have pursued 
a chronic course from the outset. It is probably due to the 
persistent presence in the circulation of some irritating toxic 
substance. It is characterized by chronic degeneration of 
the secreting epithelium and by a proUferation of the fibrous 
coimective tissue. 

The usual variety is the large while kidney. The kidney 
is much increased in size, is smooth, pale, and softer than 
normal. The capsule strips easily. The exposed surface 
presents a somewhat mottled appearance. On section the 
cortex is seen to be much thickened and ])alerthan the pyra- 
mids, which are usually congested and reddish. The cortex 
may show scattered punctate hemorrhages. 

If the nephritis has existed for a long time, the kidney 
may become smaller on account of the contraction of the 
new-formed connective tissue. The organ is then smaller 
than normal, pale, and granular, the pale granular kidney. 
The epithelium becomes markedly degenerated and the con- 
nective tissue contracts and compresses the parenchyma. 
The capsule is adherent and cannot be removed without 
bringing away portions of the kidney. 

Microscopically the chief change present is a fatty de- 
generation of the epithehum in the tubules and the glomeruli. 
The tubules may be filled with granules from the broken- 
down cells, and erythrocytes may be present. Round-cell 
infiltration of varying degrees will be founrl in the interstitial 
tissues. The Malpighian bodies generally show a prolifera- 
tion of their e[)ithelium, the capsule of Bowman may be- 
come much thickened, and the walls of the capillaries also 



DISEASES OF THE URINARY ORGANS 395 

increase in thickness. The amount of connective tissue is 
never as great as in the chronic interstitial form. 

The urine will contain granular and hyaline casts and 
varying amounts of albumin. 

Acute interstitial nephritis or suppurative nephritis is the 
result usually of hematogenic infection by micro-organisms, 
or it may be due to extension of an inflammation of the pelvis 
of the kidney or of a neighboring tissue. The organisms 
gain entrance to the kidney as emboli and usually become 
lodged in the capillaries of the glomeruli. There is an ex- 
travasation of round-cells and leukocytes into the capsular 
space and minute foci of suppuration are formed. The 
irritating products soon cause destruction, with necrosis of 
the adjacent cells. There is generally some extravasation 
of blood surrounding the areas of suppuration. The pro- 
cess may terminate by the absorption of the exudate with 
connective-tissue formation. If the lesion becomes more 
extensive distinct abscesses may form which may discharge 
into the tubules or be absorbed and cicatrized. 

If the infection has followed a suppurative pyelitis the 
kidney will be found on section to contain light yellowish 
colored streaks in the pyramids and medulla. These are com- 
posed of tubules that have become filled with pus. Some- 
times several of these foci may coalesce and form a larger 
abscess, which may discharge its contents into the pch'is 
of the kidney or uj)on the surface of the kidney; or it may 
become absorbed and undergo cicatrization. The suppura- 
tive process may go on to such a point that the entire kidney 
becomes converted into a sac filled with pus. 

Chronic interstitial nephritis is a form of kidney inflamma- 
tion characterized by a continual increase in the amount of 
interstitial connective tissue associated with an atrophy of 
the secreting cells. It is found in alcoholism, syphilis, 
chronic lead poisoning, and is frecjuenlly associated with 
general arteriosclerosis. 

The kidney is small, dark red in color, firm, and granular, 
the red granular kidney. The irregularities arc due to the 
contraction of the connective tissue. The capsule strips 



396 



A MANUAL OF PATHOLOGY 



with great difficulty, tearing away portions of the renal sub- 
stance with it. On the surface are seen small cysts filled 
with clear fluid. These are due to the obstruction of a 
tubule by the pressure of the connective tissue. The 







Fig. 151. — Chronic Interstitial Nephritis (McFarland). 
a, Still functional glomerule with (b) mass of newly formed connective 
tissue surrounding Bowman's capsule; c, totally destroyed glomerule; 
d, newly formed cellular connective tissue; c, atrophic uriniferous tubules; 
/, slightly altered uriniferous tubules. 



tissue cuts with great difficulty, being almost cartilaginous at 
times, and presents a typical appearance. The cortex is 
generally very thin with some places of almost normal thick- 
ness. Over the thin areas the capsule is usually considerably 
thickened. The medulla shows httle change. 



DISEASES OF THE URINARY ORGANS 397 

Microscopically the picture is very definite, although all 
portions of the kidney may not be equally involved. As the 
glomeruli are the parts first brought into contact with the 
circulating toxic substances, it is there, as a rule, that the 
processes begin. The glomerulus becomes slowly trans- 
formed into a more or less homogeneous body that loses all 
lobulations. At the same time the capsule becomes greatly 
thickened and the glomerulus is finally transformed into a 
minute fibrous nodule. The intertubular connective tissue 
increases until eventually the tubules may become com- 
pletely atrophic, through compression. Although many of 
the tubules are atrophic, others will be found markedly 
dilated, so much so that small cysts may form. There is also 
a thickening of the walls of the blood-vessels. All these 
processes may go on to a point where there is very little renal 
secretory structure left. The parenchyma also shows some 
changes, but not so markedly as in the chronic parenchyma- 
tous variety. There is some atrophy and fatty degeneration. 

The urine is generally increased in quantity, of a low 
specific gravity, with little or no albumin. A few casts of 
the hyaline and waxy character are found. 

Tube casts are peculiar bodies that are formed within the 
urinary tubules and that are composed of various albuminoid 
substances, some of which react like fibrin. Hyaline casts 
are pale, almost transparent, structures reacting like fibrin. 
They may vary greatly in length and also in thickness; are 
found most commonly in acute parenchymatous nephritis, 
but are also present in the chronic parenchymatous and in- 
terstitial varieties. The hyaline cast is the foundation of 
many of the other forms. Its surface is adhesive, and ac- 
cording to the substances upon it, we have granular, epithelial, 
leukocytic, and hlood casts. Some blood casts may, however, 
be formed by the coagulation of extravasated blood within a 
tubule. Granular casts may be dark or pale according to the 
amount and form of the material composing them. Are 
found usually in chronic nephritis. The waxy cast is a 
rather large, translucent, and solid appearing body that is 
found especially in chronic interstitial nephritis and in amy- 



398 A MANUAL OF PATHOLOGY 

loid diseases. At times it may give an amyloid reaction with 
iodin. 

The effects of nephritis are particularly noticeable in 
the cardiovascular system when the renal disease is of a sub- 
acute or chronic type. There is a hypertrophy of the heart, 
especially of the left ventricle, which may become greatly 
enlarged. The reason for this hypertrophy is not clearly 
understood. As the kidneys normally secrete urea, chlorids, 
phosphates, uric acid, urates, and oxahc acid, the accom- 
panying changes may be due to the retention of these sub- 
stances within the circulation. /\.s in chronic renal disease 
there is always more or less arteriosclerosis present, the 
cardiac enlargement may be due to the extra amount of work 
required to force the blood through the thickened and less 
elastic vessels. 

The serous membranes in acute nephritis may show in- 
flammatory changes, such as acute endocarditis, acute peri- 
carditis, and pleuritis. Edema is particularly common in 
acute parenchymatous nephritis, especially if the glomeruli 
and vessels are involved. The edema appears first in the 
eyelids and hands, but as the disease progresses and the 
blood-vessels degenerate it spreads over the entire body. 
Death may result from edema of the lungs. Uremia is also a 
frequent condition, due probably, to the retention within 
the circulation of various toxic substances. 

Tuberculosis of the kidney may be due to primary 
hematogenic infection or to secondary involvement following 
similar disease of other portions of the genito-urinary tract. 
It may be a part of a general miliary tuberculosis and present 
numerous minute grayish white tubercles scattered through- 
out the renal substance, particularly in the cortex. The foci 
may be surrounded by a narrow zone of congestion. 

When there has been an ascending infection from the 
ureters or a primary local tuberculosis the changes are quite 
characteristic. The process may begin as a miliary tubercle, 
which by invasion and lymphatic extension spreads through 
the organ. The apices of the pyramids are involved and the 
disease extends through them to the cortex. These areas 



DISEASES or THE URINARY ORGANS 



399 



undergo coagulation necrosis, soften, and eventually dis- 
charge their contents into the pelvis of the kidneys, leaving 
an irregular cavity. On section there are seen numerous 
large cavities communicating with the pelvis of the kidney. 
The discharged material infects the mucous covering of the 
pelvis and the dis- 
ease gradually ex- 
tends downward 
along the ureter 
until the entire 
urinary tract may 
be involved. This, 
of course, when the^ 
tuberculosis has 
been primary in 
character and not 
due to an ascending 
infection. The 
ureter may become 
obstructed, and the 
kidney undergo 
dilatation, thus 
forming a cold ab- 
scess of the kid- 
ney, the organ be- 
ing changed into a 
sac with thick walls 
and containing tu- 
bercular pus. 

Syphilis is infre- 
quent and not defi- 
nite in its manifes- 
tations. There have been found gumma giving rise to thick 
stellate scars. 

Tumors of the Kidney. — Fibromata in the form of small 
nodules are occasionally found. Llpomata and leiomyomata 
arc sometimes encountered. 

Sarcoma is quite common and is cither congenital or else 




Fig. 152. — Tuberculous Pyelonephritis 
(modified from Bollinger). 



400 



A MANUAL OF PATHOLOGY 



appears, as a rule, very early in life. The tumor may attain 
considerable size, is usually grayish in color, although it may 
be red if very vascular, and may be quite soft. Generally the 
growth is composed of round or spindle cells, but not infre- 
quently are found libers of striped muscle, the so-called 
rhabdosarcoma. Sarcoma may occasionally be found in later 

life. Such a tumor dif- 
fers from the congenital 
form in being slow in 
growth and not giving 
metastases till late. The 
congenital form is rapidly 
mahgnant and destruc- 
tive. 

Of the epithelial tu- 
mors the hypernephroma 
is the most common. It 
is derived from portions 
of adrenal tissue that 
ha\e been included with- 
in the kidney during its 
development. The struc- 
ture of the tumor resem- 
bles that of the adrenal 
gland, except that the 
cortical elements are the 
more prominent. The 
neoplasm may be small 
and remain circum- 
scribed or it may take 
on a rapid growth and 
become destructive. The 
cells contain fat and gly- 
cogen. 
Adenoma is rare. It occurs as small circumscribed nodules 
composed of glandular alveoli, which may show papillary out- 
growths and also at times be cvstic. 
Carcinoma as a primary growth is unusual and s-econdary 




Fig. 153. — Congenital Cystic Kidney 
(Specimen 2816, Museum N. Y. 
Hosp.). 



DISEASES OF TPIE URINARY ORGANS 40I 

metastases are not common. The secondary form makes its 
appearance as small scattered nodules. The carcinoma 
may become quite large, and destroy the renal tissue, and is 
frecjuently associated with hemorrhages into the tissue. 

Cysts of the kidney are quite common and are of various 
forms. They may be single or multiple, large or small. In 
the majority of cases they appear as numerous small collec- 
tions of fluid scattered over the surface of the kidney. They 
are simple retention cysts due to the obstruction of the tubule 
below the glomerulus; are especially common in chronic in- 
terstitial nephritis. Occasionally a kidney may contain a 
single large cyst and otherwise be apparently normal. Is 
probably due to the obstruction of a tubule. 

The kidneys may be congenitally cystic, and in such a case 
present a characteristic appearance. Both kidneys are 
generally affected and are filled with numerous cysts, some of 
which may be as large as a walnut. These may be filled 
with a urinous or even a colloid material, and are separated 
from each other by a very thin stroma of connective tissue. The 
organs may be very much enlarged. Generally such a condi- 
tion is incompatible with life, but similar lesions may be found 
in adults. As long as the remaining renal substance is able 
to maintain the excretion the individual will live, but when the 
organs become incompetent death may ensue from uremia. 

Hydronephrosis is a cystic dilatation of the kidney resulting 
from an obstruction of the ureter. When the ureter is ob- 
structed, as by a calculus, by inflammatory changes, by 
twists or kinks, or by pressure from new growths either 
within or similar conditions on the outside, it and the pelvis 
of the kidney will begin to dilate. The urine, being unable 
to escape, collects and gradually causes the tissues to stretch. 
The pelvis becomes larger, the calices arc flattened out, and 
the renal tissue becomes atrophic until, as a result of the com- 
bined pressure and atrophy, there is a mere shell of kidney 
substance remaining. The fluid contained within the sac 
is at first practically normal urine. As long as there is any 
secretory tissue left urine is excreted, but when that ceases 
the salts in the fluid are either precipitated or absorbed and 
26 



402 A MANUAL OF PATHOLOGY 

the remaining liquid is watery. Such cysts may become in- 
fected or hemorrhages may take place within them. When 
filled with pus, the condition is known as pyonephrosis. 

Nephrolithiasis. — Renal calculi are quite frequently 
found in the pelvis of the kidney and are composed of material 
precipitated from the urine. They may occur in the form of 
fine particles Hke sand or they may be so large as to be unable 
to pass out through the center. When small, the calcuH can 
pass from the kidney without giving any pain. As they 
become larger they may pass out and give rise to severe renal 
colic; if quite large, the ureter may be completely blocked, and 
dilatation and atrophy follow. The concretions may also 
vary in shape, some being round and smooth, while others 
may be very rough, and if large send prolongations into the 
calices. The commonest variety is composed of uric acid 
and oxalate of hme, but phosphatic stones arc found occasion- 
ally. The color varies according to whether uric acid and 
urates or the phosphates predominate. 

The presence of calculi may cause degeneration and 
atrophy as a result of pressure, and suppuration is quite com- 
mon. Obstruction of the ureter gives rise to varying degrees 
of hydronephrosis. 

The presence of calcuh seems occasionally to antedate the 
formation of a carcinoma. 

DISEASES OF THE URETER 

There may be obstructions due to congenital atresia or to 
various diseases and neoplasms. The result of such a con- 
dition is a dilatation of the ureter above the obstruction and 
of the kidney (hydronephrosis). 

Pyelitis, or inflammation of the pelvis of the kidney, is 
met with in the course of various infectious diseases, as 
typhoid fever, scarlet fever, smallpox. In such cases is 
seldom of any severity. The most important causes are 
local infection and calculi. Infection may take place through 
the presence of pyogenic organisms within the urinary ap- 
paratus, and according to the degree of severity the inflam- 
mation may be catarrhal, hemorrhagic, suppurative, pseudo- 



DISEASES OF THE URINARY ORGANS 403 

membranous, or ulcerative. In the suppurative form there 
is nearly always an involvement of the renal tissue, a pyelone- 
phritis. If the ulcerated form is severe, perforation may 
take place and the purulent contents escape into the sur- 
rounding tissue, giving rise to a perinephritic abscess, the pus 
collecting in the areolar and fatty tissue about the kidney. It 
may remain encapsulated, and compress the kidney, or it may 




Fig. 154. — Tuberculous Nodule in the Wall of the Ureter, with 
Beginning Hydronephrosis (from a specimen in the Museum of 
the Philadelphia Hospital, Phila.). 

burrow through the deeper tissues and discharge below 
Poupart's ligament. 

In chronic pyelitis the mucous membrane may become 
much thickened, contain ulcerations, and be covered in places 
by a precipitation of the salts from the urine. The kidney 
in this form is often the scat of chronic inflammation, sup- 
puration, or atrophy. 

If the ureter becomes obstructed, the pelvis of the kidney 
may be filled with pus, a pyonephrosis. 



404 A MANUAL OF PATHOLOGY 

Calculi may lodge within the ureter and give rise to vary- 
ing disturbances, from acute renal colic to obstruction with 
subsequent hydronephrosis. Hemorrhage may be caused by 
laceration of the mucous membrane and suppuration is not 
uncommon. 

Parasites at times find their way into the ureters and pass 
up to the kidney. A ureter may also become the seat of tuber- 
cular changes. 

DISEASES OF THE BLADDER 

Malformations of the bladder are quite common. The 
most usual form is a lack of union along the anterior median 
line with faihire of closure of the abdominal wall, exstrophy 
of the bladder. Is usually associated with epispadias, or 
with division of the clitoris. Occasionally there may be a 
communication with the rectum or the vagina. Sometimes 
there is no urethra. 

The urachus may remain patulous and urine be discharged 
at the umbilicus or may be retained in the anterior abdo- 
minal wall as a cyst. Diverticula may occur, usually in the 
anterior wall. The bladder may be completely lacking, 
the ureters emptying directly into the urethra, or the organ 
may be divided into two portions by a septum. 

Hypertrophy of the bladder may follow any chronic in- 
terference to the outflow of urine. The muscular coat of 
the wall becomes much thickened and the mucous membrane 
also increases in thickness and is thrown into folds. In- 
dications of chronic inflammation are also usually present. 

Dilatation of the bladder may be congenital or acquired. 
It is due eitherto obstruction tothe escape of urineortoparaly- 
sis of the muscular coat of the wall. As a rule, the condition 
results from long-continued interference with the escape of 
urine, and is accompanied by a hypertrophy of the walls with 
thickening of the mucosa. The fibrous bands are prominent 
and the mucosa in between is pouched. Diverticula are 
quite frequent. If the dilatation has taken place suddenly, 
as in paralysis, the vesical walls are very thin. Such a 
weakening is often accompanied by rupture, with peritonitis. 



DISEASES OF THE URINARY ORGANS 405 

The bladder may occupy an abdominal position, particularly 
in women, when there has been some laceration of the per- 
ineum. Its walls may prolapse into the vagina, forming a 
cystocele. At times it may be completely inverted. 

Rupture of the bladder may follow severe injury or acute 
dilatation. The rupture generally occurs at the base and is 
followed by peritonitis and death. As a result of traumatism 
the injury commonly occurs near the neck of the bladder and 
is followed by extravasation of urine into the surrounding 
tissue, which generally gives rise to a severe phlegmonous 
cellulitis. 

Fistulous communications with the vagina or rectum are 
not uncommon in women as a result of injuries received dur- 
ing childbirth. 

Circulatory Disturbances.— yld/Ve hyperemia is usually 
dependent upon infection by some micro-organism or due to 
the presence in the urine of irritating substances. The mu- 
cous membrane is diffusely red. 

Passive hyperemia is due to thrombosis of or pressure upon 
the inferior vena cava. The mucous membrane is dark red 
in color, the vesical veins at the neck of the bladder become 
distended and varicose, and there is some catarrhal inflamma- 
tion. Severe hemorrhage may occur from a rupture of one 
of the varicose veins or the veins may be the seat of thrombosis. 

Hemorrhage may be caused by injuries, calculi, malignant 
disease or result from ruptured varicose veins. 

Inflammation. — Acute cystitis, inflammation of the blad- 
der, maybe due to the presence of pus-producing organisms 
that have gained entrance from the urethra or to the presence 
of irritating substances within the urine. The infecting 
agent may have been introduced by the use of unclean in- 
struments in catheterization. The bladder is usually empty 
or else contains a small amount of cloudy urine that throws 
down a sediment composed of desquamated epithelium, 
mucus, pus cells, and bacteria. The mucosa is hypcremic, 
swollen, and edematous. The process may subside in a 
short time or it may become pseudo-membranous . The in- 
flammation extends into the deeper tissues, necrosis of the 



4o6 A MANUAL OF PATHOLOGY 

epithelium with ulceration takes place, and over these areas 
is formed a pseudo-membrane. The greater part of the 
vesical walls may be thus covered. 

Phlegmonous cystitis may be a further stage of the above 
processes, but it usually results from a rupture of the blad- 
der. The vesical walls and the surrounding tissues become 
infected and are the seat of abscess formation. 

Chronic cystitis may follow acute inflammation, but is 
generally caused by some chronic obstruction to the escape 
of urine. As a result of obstruction there is a retention of 
urine with subsequent infection. Decomposition follows 
and the irritating products set up a chronic inflammation. 
The mucous membrane becomes much thickened and even 
polypoid, is reddened, and frequently ulcerated. Lime 
salts may be deposited in the degenerated tissues. The 
muscular fibers hypertrophy, but they gradually lose their 
strength and the urine is not discharged. Hemorrhages 
into the vesical walls are common. 

As a result of injuries to the spinal cord the bladder may 
undergo a rapid dilatation and the walls at the same time have 
their nutrition interfered with. The urine rapidly collects, 
undergoes fermentative processes, and causes necrosis of 
the mucous membrane. This may be followed by perforation 
with fatal peritonitis and at times gangrene. 

Tuberculosis of the bladder is generally secondary to 
tuberculosis of the epididymis, seminal vesicles, or prostate, or 
oc-curs as a descending infection from disease of the kidney. 
The disease manifests itself in the form of ulcers that are 
commonly located in the trigone, from which they may ex- 
tend upward, involving the lower half of the bladder. The 
involved areas undergo cheesy degeneration and are frequently 
the seat of a deposit of urinary salts. There is usually a 
chronic cystitis present. Tuberculosis of the bladder is very 
much more common in men than in women. Primary tuber- 
culosis is extremely rare and syphilitic ulcers are also very 
unusual. 

Vesical calculi are very frequently encountered. They 
are composed of substances normally or abnormally present 



DISEASES OF THE URINARY ORGANS 



407 



in the urine. They may be present in great numbers, when 
they are small, Hke fine particles of sand, or singly as one 
large stone several centimeters in diameter and weighing as 
much as 1000 gm. The shape and the general character- 
istics of the calcuh depend upon the material of which they 
are formed. The stones may be imbedded within the mu- 




FiG. 155. — Urinary Calculi (Orth). 
Showing the nuclei from which they originate, the concentric lamina? 
by which they are formed, the radiating infiltration sometimes observed, 
and the various smooth and nodular surfaces. 



cosa or they may lie free within the bladder. In the latter 
case the sides of the stones may be worn smooth by mutual 
contact. 

The formation of a stone is s^cnerallv considered to be due 
to the precipitation of the various salts about some desqua- 



4oS A MANUAL OF PATHOLOGY 

mated epithelium or foreign body. This is accompanied by a 
coagulation of albuminous material about the calculus and 
then another layer of mineral salts, giving a distinctly lami- 
nated appearance to the stone. Occasionally the nucleus 
may be a renal calculus that has passed through the ureter. 
It is usually of a different composition than those formed 
within the bladder. 

Associated with the formation of calculi is generally a 
retention of urine. 

These stones may be made up of uric acid or urates, of 
oxalate of Hme, of phosphates, of carbonate of hme, or of 
various organic bodies, as cystin or xanthin. 

The characteristics of the various calculi are as follows: 

1. Uric acid, are less common in the bladder than in the 
kidney. Are small, round, hard, slightly granular surface, 
of a yellowish, reddish, or brownish color. They probably 
originate within the kidney. 

2. Urates, of ammonium magnesium, often are covered 
by earthy phosphates. May be as large as a hen's egg, oval, 
smooth surface, pale in color, and laminated. If composed 
entirely of ammonium urate are seldom larger than a pigeon's 
egg, rounded but also flattened, friable, granular, and dull 
yellow. 

3. Calcium pJiosphatc, medium-sized, irregular surface, 
grayish in color, hard and brittle, or soft and crumbling if 
there is much triple phosphate present. Frequently form 
about small uric acid calculi. 

4. Triple phosphates, large, irregular, grayish, soft, and 
friable. 

5. Carbonate oj lime, are rare, are small, white, and chalky. 

6. Oxalate oj lime, are round, brownish color, surface 
irregular and nodular, very hard, may be quite large. Are 
the mulberry calculi. 

7. Cystin, unusual, small, oval, brownish or greenish, 
soft and waxy. 

8. Xanthin, very rare, small brownish, smooth surface, and 
brittle. 

Results of the vesical calculi are many. Their presence 



DISEASES OF THE URINARY ORGANS 



409 



may cause obstruction to the outflow of urine with subse- 
quent dilatation of the bladder and its accompanying chronic 
cystitis. By pressure, atrophy and ulceration of the mucous 
membrane may take place with even perforation. Hyper- 
trophy of the vesical walls occurs. There are frequent at- 
tempts at micturition, accompanied by straining and tenesmus, 
with frequently bloody urine. If long continued the obstruc- 



l^-^lry 




Fig. 1 56. — Papilloma of the Bladder. X 35 (Ziegler). ( Alk. Hiim. Eos.) 
Section through a tuft. 



tion may give rise to bilateral hydronephrosis or pyonephro- 
sis if the infection extends upward. 

Sometimes the calculus may become lodged in a pouch 
of the wall and become completely encapsulated. 

Tumors. — Polypoid thickenings of the mucosa arc quite 
frequently found in chronic inflammations of the bladder. 
Fibromata generally appear as small villous outgrowths, 
covered by epithelium. Are very vascular and may give rise 
to such considerable hemorrhage that grave or fatal anemia 



4IO A MANUAL OF PATHOLOGY 

ensues. Occasionally bits of the papillary growths may break 
off and be passed through the urethra or they may be large 
enough to cause obstruction. These tumors are benign, 
but there is a possibihty of their becoming malignant. True 
connective-tissue tumors, particularly sarcoma, are rare. 
Carcinoma in the form of a squamous epithelioma is an in- 
frequent primary tumor. It occurs as a cauliflower mass 
that frequently undergoes ulceration. The neighboring 
organs are generally involved by contiguity. Secondary 
carcinoma may follow malignant disease of the sexual organs, 
of the rectum, or of the prostate by direct extension. The 
bladder is very rarely the seat of a metastatic growth. Cysts 
very rarely are found. 



DISEASES OF THE URETHRA 

Malformations. — Occasionally the urethra may be absent, 
or the superior or inferior walls may be incomplete, giving 
rise to epispadias and hypospadias respectively. 

Inflammation. — Urethritis, inflammation of the urethra, 
is nearly always an infectious condition resulting from the 
presence of the gonococcus. Non-specific urethritis may be 
due to injuries or to the entrance of pyogenic micro-organisms. 
In gonorrheal urethritis the mucosa of the anterior urethra is 
first involved. It becomes red and swollen and there is soon 
a formation of pus accompanied by a desquamation of the 
epithehum. In the pus cells as well as in the epithehal the 
characteristic organisms will be found. There is generally 
an infiltration into the deeper layers of the mucosa by the 
gonococci. The infection may extend to the posterior 
urethra, and involve the bladder, epididymis, prostate, 
seminal vesicles, and in women the bladder, vagina, uterus, 
and Fallopian tubes. 

The inflammation in the urethra may subside without do- 
ing any damage or it may set up infectious processes in other 
parts of the body. Is not uncommon to have a gonorrheal 
ophthalmia, gonorrheal arthritis, an acute endocarditis, or 
pericarditis. 



DISEASES OF THE URINARY ORGANS 411 

The acute form of urethritis is often followed by a chronic 
inflammation called gleet. The posterior urethra is the part 
generally involved and is accompanied by a very slight dis- 
charge of a thick transparent mucus seen in the morning. 
Not infrequently a fibrous cicatrix is formed in the urethra. 
This undergoing contraction gives rise to a stricture which 
is most commonly located in the membranous portion. If the 
narrowing is severe, the urine may be prevented from es- 
caping, and consequently cause a dilatation of the bladder 
with hypertrophy and chronic cystitis. The ureters and kid- 
neys may even be involved. 

Injuries. — ^The urethra may be the scat of various in- 
juries resulting from direct trauma, external or internal. If 
it is completely lacerated urine is able to escape into the 
tissues and rapidly give rise to a suppurative or gangrenous 
cellulitis. This may be very widespread, including the lower 
half of the abdomen and the upper part of the thighs. Fis- 
tulas communicating with the vagina or rectum or opening 
externally may be formed. 

Tuberculosis and syphilis are rare. 

Tumors of the urethra are unusual except when secon- 
darily involved by a neoplasm in adjacent structures, as in 
squamous epithelioma of the glans penis or in carcinoma of 
the prostate; in women in cancer of the cervix. The urethral 
canmcle, found in the meatus in women, is a fibrous angioma. 
Sarcoma, myxoma, and fibroma sometimes occur. 



CHAPTER XXIII 

DISEASES OF THE REPRODUCTIVE SYSTEM 

Male Organs 
the penis 

Malformations of the Penis. — The penis may be absent, 
undeveloped, or, what is very rare, double. There may be 
lack of closure of the urethra on the dorsal surface, epispadias, 
or, on the under side, hypospadias. In the latter condition 
the cleft may extend posteriorly and separate the scrotum 
into two lateral halves. This is usually the condition in the 
cases of hermaphrodism. Epispadias may be associated 
with exstrophy of the bladder. The pre]3uce may be absent 
or, what is quite common, elongated and the orifice greatly 
narrowed; is termed phimosis. 

Inflammation of the glans penis is known as balanitis, of 
the prepuce as posthitis, of the two together as bala^to- posthitis. 
Is generally the result of uncleanh'ness. Is a quite common 
complication in phimosis when the prepuce cannot be re- 
tracted. The smegma and urine undergo decomposition and 
set up an inflammation; infection, as in gonorrhea, may be 
the cause. Occasionally the prepuce when inflamed may be 
retracted behind the glans and unable to be drawn forward. 
Is called paraphimosis, and by its constriction may give rise 
to serious secondary conditions. 

Injuries to the })enis may give rise to hemorrhage or to rup- 
ture. If it becomes infected suppuration and gangrene may 
result. If the urethra has been lacerated extravasation of 
urine with its accompanying symptoms may occur. In- 
juries are likely to be more severe when the penis is in an 
erect condition. 

412 



DISEASES OF THE REPRODUCTIVE SYSTEM 413 

Tuberculosis is rare. It appears as ulcerations on the 
glans with cicatrization and necrosis. 

Syphilis generally makes its initial appearance on the 
penis as the true chancre. 

Tumors of the penis are frequently found and are gen- 
erally epithelial in structure. The papilloma or condyloma 
appears as a hard, rough, cauhtiower-like growth upon the 
glans penis or prepuce. Is composed of vascular connective- 
tissue villosities covered by squamous epithelium. Car- 
cinoma usually occurs in the form of the squamous epithelioma 
arising from the glans or the prepuce. It is generally warty 
and prone to ulcerate. Large areas of the penis may be 
destroyed and metastases to the neighboring inguinal l}mph- 
nodes occur. The connective-tissue tumors are rare. 

Scrotum. — Is quite frequently the scat of epithelioma in 
chimney-sweepers and paraffin-workers. Elephantiasis is 
common in the East and in many cases is due to the filariic. 
The subcutaneous tissue is greatly increased, so that an ex- 
treme enlargement may occur. ID cr moid cysts are occasion- 
ally met with. 

THE TESTICLES 

Malformations. — One or both testicles may be absent or 
hypoplastic. CryptorcJiia is a conchtion in which one or both 
testicles instead of descending into the scrotum remain within 
the abdominal cavity or in the inguinal canal. Occasionally 
the testicles may not descend till ])uberty. The unde- 
scended testicles are usually small and im})erfectly developed, 
and are not uncommonly the seat of a sarcomatous prolifera- 
tion. 

Atrophy of the testicle occurs in senility and after chronic 
intlammations. The organ is small and dense, is dark in 
color, and is incapable of spermatogenesis, the cpithehum 
having undergone a fatty degeneration. 

Hypertrophy has been noticed as a compensatory change 
following the removal of one testis and is characterized by an 
increase in size of the seminiferous tubules. 

Fatty degeneration is quite frequently observed as a 



414 A MANUAL OF PATHOLOGY 

result of pressure from tumors or from other pathologic con- 
ditions within the testicle. 

Inflammation of the testes — orchitis — and of the epididy- 
mis — epididymitis — are commonly encountered. The two 
may occur together or alone. If the surrounding tunica 
albuginea is involved the condition is called periorchitis. 

The inflammation may be due to traumatism or to in- 
fection, the latter usually resulting from the extension of a 
gonorrhea. In typhoid fever, scarlet fever, syphilis, smallpox, 
and mumps the testicles are occasionally the seat of inflam- 
matory changes, as a result of hematogenous infection. The 
traumatic and gonorrheal processes generally involve the 
epididymis only. 

Orchitis may be acute or chronic. In the acute form the 
testicle is swollen, hard, and very painful on account of the 
organ being inclosed within the fibrous tunica albuginea. 
Microscopically there is seen a marked round-cell infiltration 
between the tubules. The epithelial cells degenerate and 
desquamate. The condition may terminate in suppuration; 
and if the tunica is broken through, the testicular substance 
may protrude and form a fungous condition. The organ 
may, on the other hand, entirely recover. 

Chronic orchitis usually follows the acute variety or as a 
complication of syphilis. In it there is a great hyperplasia of 
the intcrtubular connective tissue with subsequent contrac- 
tion, atrophy, and degeneration, the testicle becoming very 
dense. 

In epididymitis that structure becomes much swollen and 
painful and is usually associated with a serous exudation into 
the tunica vaginalis. 

Tuberculosis generally is primary in the epididymis and 
secondarily involves the testicles. The infecting organisms 
may gain entrance either through the circulation or from the 
urethra through the vas deferens. In the latter form there 
has generally been a pre-existing tuberculosis of the seminal 
vesicles, prostate, or bladder. 

The condition is, as a rule, secondary to pulmonary tubercu- 
losis, small tubercles develop, these increase in size, coalesce, 



DISEASES OF THE REPRODUCTIVE SYSTEM 415 

and form quite large caseous masses which may break down 
and rupture externally. 

Syphilis, either acquired or congenital, may give rise to 
changes in testicles and epididymis; the testicle usually being 
involved secondarily. There is generally an intertubular 
round-cell infiltration with induration and degeneration of the 
tubular epithelium. Gummata sometimes form and undergo 
a caseous degeneration with subsequent cicatrization. 

Leprosy of the testicle in the form of nodular formations, 
with degeneration and atrophy of the tubules, has been noted. 

Tumors. — Fibroma, lipoma, and myxoma are sometimes 
encountered. Chondroma and rhabdomyoma have been de- 
scribed. Sarcoma in all varieties occurs in the testicle, less 
commonly in the epididymis. Secondary changes frequently 
occur, and cysts of various sizes may form. Combinations 
of the sarcoma with chondroma, lipoma, libroma, etc., are 
quite common. 

There have also been described tumors of the testicle 
that contain areas resembling the chorioepitheliomata that are 
found in women. 

Adenoma is rare; when present it is generally associated 
with carcinomatous proliferation of the epithelium. Car- 
cinoma is not unusual, and though usually medullary in type 
may be scirrhus. Is frequently associated with cystic dila- 
tations of the tubules. Various degenerations, as mucoid and 
colloid, are quite commonly seen. Although the tumor 
originates within the cells of the seminiferous tubules of the 
testicle the epididymis and vas are soon involved, the entire 
organ being transformed into carcinomatous tissue. 

Cysts. — Spermatocele is the term applied to a cystic dilata- 
tion of a seminal tubule, usually at the head of the epididymis. 
It may be quite large, containing up to 350 c.c. of a watery, 
slightly turbid fluid in which spermatozoa, either active or 
dead, may be found. Retention cysts may occur as a result 
of inflammatory changes, or to obstruction of the tubules 
by some new growth. Are spoken of as galactoceles when 
the contents are milky in color. Dermoid cysts are rarely 
found. 



4l6 A MANUAL OF PATHOLOGY 

Vaginitis testis, or periorchitis, is an inflammation of 
the tunica vaginalis. It occurs as a result of inflammation of 
the testicle or epididymis, in the course of various infectious 
diseases or in consequence of traumatism. The most com- 
mon form is the serofibrinous variety in which there is an ac- 
cumulation of serous fluid within the tunica vaginalis, giving 
rise to a hydrocele. The process may continue slowly and 
the tunica be tremendously distended by a clear straw-col- 
ored fluid. In acute cases the fluid may be purulent or 
hemorrhagic. 

If the hydrocele has continued a long time the tunica 
vaginalis becomes much thickened and the testicle and 
epididymis frequently atrophic. 

THE SEMINAL VESICLES 

Vesiculitis, or inflammation, generally follows an attack 
of gonorrhea or of prostatitis. The tubules become dilated 
by a mucopurulent exudate, are congested and tender, and in 
chronic inflammation, there may be a connective-tissue 
formation. This through contraction may give rise to various 
deformities. Obstruction to the tubules as they enter the 
prostatic tissue causes the dilatation. 

Tuberculosis may be primary or secondary to tuberculosis 
of the pulmonary or genito-urihary tracts. The bacilli gain 
lodgment by means of the blood-vessels or lymphatics. They 
are present in the semen and when contained within the 
vesicles infect them. 

Tumors are seldom primary, usually being secondary to 
carcinoma of the prostate or rectum. 

THE PROSTATE GLAND 

Atrophy of the prostate is common in old age, the 
gland becoming smaUer through degeneration of the epithe- 
lium with contraction of the fibrous tissue. 

Hypertrophy also frequently occurs in old men. The 
entire gland or any one of its lobes may increase in size. Al- 
though the gland is composed of two lobes connected by a 
narrow isthmus the hypertrophy can involve the isthmus 



DISEASES OF THE REPRODUCTIVE SYSTEM 417 




Fig. 157. — Hypertrophy of the Middle Lobe of the Prostate (White 

and Wood). 
A, Middle lobe of prostate; B, urethra. 



27 



4i8 



A MANUAL OF PATHOLOGY 



alone and cause a great increase in size. This median en- 
largement is the most important, as it is the one in which 
there are severe clinical symptoms. By the hypertrophy of 
this portion the opening to the urethra is obstructed and re- 
tention of urine occurs. This may at first merely give rise 
to increase in the thickness of the muscle-fibers and dilatation 




Fig. 158.— Hypertrophy of the Prostate Gland (McFarland). 



of the bladder. Subsequently infection takes place, the urine 
decomposes, and the bladder is no longer able to expel the 
urine. Pyelitis and pyelonephritis may follow. 

Microscopically the enlargement is due either to a glandular 
increase or to a hyperplasia of the fibrous connective-tissue 



DISEASES OF THE REPRODUCTIVE SYSTEM 419 

stroma. In the latter case there may be more or less wide- 
spread atrophy of the tubules. In the glandular form the 
appearance closely simulates that of an adenoma. 

The enlargement may result from a chronic posterior ure- 
thritis or a long- continued congestion. 

Prostatitis, inflammation of the prostate, is nearly al- 
ways secondary to a posterior urethritis, but may follow in- 
jury to the perineum. In the acute infectious form there is a 
desquamation of the glandular epithehum, with collections of 
pus in the acini, and a round-cell infiltration of the inter- 
stitial tissue. There may be numerous foci of suppuration 
scattered throughout the tissue. Large abscesses may form 
and these generally evacuate into the urethra. If further 
infection of the surrounding tissues does not occur cicatriza- 
tion and recovery take place. 

With the opening into the urethra there may be an extra- 
vasation of urine with phlegmonous inflammation of the pel- 
vic tissues. 

If the abscesses do not rupture, they may be absorbed or 
become inspissated, encapsulated, and calcified. 

Concretions are quite frequently found in the prostatic 
alveoli in old men. They are generally numerous and vary 
in size from the microscopic to those large enough to be seen 
with the naked eye. They are round, translucent, colorless 
bodies that show a distinct concentric arrangement. The 
older ones are of a slight brownish tinge. They are fre- 
quently spoken of as corpora amylacea on account of their so 
often giving a starch reaction, coloring blue or a mahogany- 
brown color with iodin. They may, however, not stain at all. 
As they become larger, lime-salts are commonly deposited 
around them. Occasionally the concretions may be so 
large as to cause the ducts to dilate. At times they escape into 
the urethra and are passed out with the urine. 

Tuberculosis of the prostate is generally secondary to 
tuberculosis of the other genito-urinary structures, particularly 
of the vas deferens and epididymis. Throughout the gland 
there are caseous masses varying in size. These may be- 
come encapsulated and calcified or may rupture into neighbor- 



420 A MANUAL OF PATHOLOGY 

ing tissues. Primary tuberculosis sometimes occurs as a 
hematogenic infection, but is quite rare. 

Tumors of the prostate are not common. Sarcoma and 
adenoma are very rare. Carcinoma is more frequent, but even 
it is unusual either as a primary or a secondary growth. It 
may occur in rather young individuals and appears as a 
nodular yellowish mass that projects into the bladder and 
urethra. It soon breaks down, leaving an ulcerated surface. 
Extension usually involves the bladder and rectum, but 
metastases to the inguinal nodes or more distant organs fre- 
quently take place; death rapidly ensuing. 

Cysts are very rare, occasionally arising from remnants of 
Mueller's ducts or from obstruction to the ducts. 



COWPER'S GLANDS 

These become involved in the course of inflammations of 
the prostate gland or of the urethra. The glands become 
hyperemic, enlarge, and may suppurate. The abscess may 
rupture into the urethra or externally, in either case giving 
rise to a fistula. The duct may become narrowed as a result 
of inflammation and form a retention cyst. 

The Female Organs 
the ovaries 

Malformations. — The ovaries may be hypoplastic or oc- 
casionally one may be absent, seldom both. An ovary may be 
much displaced, sometimes being found in the inguinal canal 
or in the labium majus. It may also be displaced as a re- 
sult of a change of position in the uterus or from pressure or 
adhesions. 

Circulatory Disturbances. — Active hyperemia may be 
either pathologic or physiologic; in the first as a beginning 
inflammation or in the latter during the menstrual period. 

Chronic hyperemia is found in chronic heart disease or as a 
result of some localized obstruction. 

Hemorrhage takes place when a follicle is ruptured. The 
blood escapes into the folKcle after the ovum has been cast 



DISEASES OF THE REPRODUCTIVE SYSTEM 42 1 

off and at the same time the cells lining the follicle prohferate. 
They soon undergo fatty degeneration, forming the corpus lu- 
teiim of menstmation. The blood is finally absorbed, the cells 
break down, and organization takes place, leaving a small 
scar. When impregnation has occurred the corpus luteum is 
considerably larger than the above, and there is a more marked 
prohferation of the follicular cells. Instead of rapidly or- 
ganizing it may persist even to the end of pregnancy. It con- 
tains a translucent gelatinous substance and little blood. 
The luteal cells are arranged in peculiar fan-like folds. 

Oophoritis, or inflammation of the ovaries, is generally 
secondary to an inflammatory condition of the Fallopian 
tubes or of the peritoneum. Is generally due to the presence 
of pyogenic organisms which may infect the ovary by direct 
contact, as in peritonitis, or be carried in the blood- or lymph- 
vessels. 

The ovary is much enlarged and congested and round- 
cell infiltration is common. Small abscesses may appear as 
minute yellowish points. Occasionally larger collections of 
pus form and these may rupture into the peritoneal cavity or 
into a loop of intestine. Generally the inflammation quiets 
down with absorption or inspissation of the abscesses and 
terminates in connective-tissue formation, chronic oophoritis. 
As a gradual transformation of the ovary into fibrous tissue is 
a normal process as the person advances in age, the change 
cannot always be attributed to inflammatory processes. 

Adhesions frequently follow oophoritis and may cause 
serious trouble by their presence. 

Tumors of the ovary are, as a rule, cystic in character. 

Small jollicular cysts may occur singly or multiple, as a 
result of the failure to discharge the ovum, with subsequent 
enlargement of the follicle. They may become as large as a 
man's fist and contain a thin or jelly-like fluid that is usually 
clear but which may be discolored by the presence of blood. 
Such cysts are lined by a single layer of flattened epithelium, 
and are formed within the ovarian tissue. 

The neoplastic cysts dift'cr from the follicular in that the 
dilated spaces are surrounded by fibrous tissue that supports 



422 A MANUAL OF PATHOLOGY 

a vascular basement membrane upon which the cells rest. 
The epithelium is usually columnar and rarely is ciliated. 
These cysts are probably developed from Pfluger's tubes, and 
represent a cystic adenoma. 

Instead of being single they are multilocular, and may be 
divided into two groups — the simple cystoma and the papillary 
cystoma. The material contained within the cysts is usually 
clear and gelatinous, if there has not been an admixture of 
blood. Although this substance closely resembles mucin it 
is not precipitated by acetic acid, consequently it is known as 
pseiidomucin. 

The simple cystoma is a benign growth and retains to some 
extent a glandular arrangement, in that there are formed 
acini lined by epithelium. It is usually multilocular, al- 
though in many instances the septa between the acini have 
been broken. The contents are usually thick and viscid on 
account of the pseudomucin present. This substance is less 
frequently found in the papillary cystoma. 

At times the proliferation of the epithelium may take on a 
malignant tendency and give rise to a carcinomatous degen- 
eration. This is more frequent in the papillary variety. 

The papillary cystoma are generally bilateral and probably 
originate from the paroophoron. From the inner surface of 
the cyst there extend papillary outgrowths covered by a strati- 
fied layer of cihated columnar epithelial cells, many of which 
are of the goblet type. The fibrous framework is less marked, 
and concentric calcareous bodies (psammoma bodies) may 
be found within it. The substance in these cysts resembles 
that found in the simple form, except that there is a less 
amount of pseudomucin. 

This form is much more inclined to undergo a secondary 
malignant degeneration than is the simple cystoma. The 
growth may be so rapid as to cause the wall of the cyst to 
rupture and the papillary structures project on the surface, 
giving rise to a cauHflower-like mass. 

Dermoid cysts are more commonly found in the ovaries than 
in any other part of the body. They may be very small or 
large, and though generally unilateral may occur in both 



DISEASES OF THE REPRODUCTIVE SYSTEM 423 

ovaries. Their structure and origin has already been de- 
scribed. Their origin has been explained as a j(etus in jelu, 
or as a result of parthenogenesis of an unfertilized ovum. 

Tumors. — Carcinoma of the ovary is nearly always a 
primary growth. It is glandular in character and generally 
undergoes a mucous degeneration. It usually gives a wide- 



VvV^. ^ ?^' '"^^ .\/v^V-'?'/'-*/-V-'-*v'V./..' I"'^ 






Fig. 15Q. — Papillaky Cystoma of the Ovary. X 150 (Ziegler). 



spread metastasis along the peritoneum. Is not infrequent in 
childhood, and is rapidly fatal. 

Fibroma may be found singly or multiple. They probably 
originate from the scars formed in the organization of the 
corpora luteii. Combination with sarcoma, fibrosarcoma, 
sometimes occurs. Myofihroma are also met with. Chon- 
droma is rare. Sarcoma is rare, but may occur as a spindle 



424 A MANUAL OF PATHOLOGY 

cell or, more rarely, as a round-cell variety. Myxomatous 
degeneration is common. Metastasis is unusual, and the 
malignancy of these growths is slight. If there are many 
glandular structures present the neoplasm is called an 
adcnosarcoma. Angiosarcoma occasionally occurs. Endo- 
thelioma is unusual. 

THE FALLOPIAN TUBES 

Malformations of the tubes are not frequent. Are 
usually associated with abnormahties of the uterus. They 
may occupy unusual positions as a result generally of ad- 
hesions. 

Hyperemia of the tubes occurs in the early stage of in- 
flammation and during menstruation. Hemorrhage is rare, 
except from a rupture of the tube in an ectopic pregnancy. 

Salpingitis or inflammation of the tube is always the re- 
sult of infection by micro-organisms gaining entrance from 
the uterus. It may be acute or chronic, and the most com- 
mon cause is the gonococcus. Is also generally present in 
puerperal infections. 

In the acute form the mucous membrane of the tube shows a 
catarrhal inflammation with an accompanying exudation. 
This latter varying according to the severity of the inflamma- 
tion, being mucous, purulent, or hemorrhagic. There is a 
marked round-cell infiltration of the mucosa, and many of 
the epithelial cells may desquamate. 

The exudate escapes from the fimbriated end of the tube, 
and sets up an inflammation of the adjacent tissues with the 
formation of adhesions. If the uterine end becomes ob- 
structed the exudation may be retained. If the contents are 
purulent a pyosalpinx is formed; if much blood is present, a 
hematosalpinx; and when serous, the condition is called a hy- 
dorsalpinx. If the secretion of fluid continues the tube may 
become much dilated with any of the above contents. The 
walls will become thinner and rupture may occur. The con- 
tents may be discharged into the abdominal cavity, into the 
intestine, or be walled in by adhesions. If rupture occurs 
during the acute stage general peritonitis wiU usually result. 



DISEASES OF THE REPRODUCTIVE SYSTEM 425 

If, however, the condition has been chronic the exudation is 
nearly always sterile on account of the death of the infecting 
bacteria. 

In chronic salpingitis there is a hyperplasia of the connec- 
tive tissue and muscularis; it is generally secondary to an acute 
infection. The tube-walls become much thickened, and ad- 
hesions to the outer surface are present. They may cause 
considerable distortion. 

The contents of the tube may gradually be absorbed or 
calcareous material may be deposited. 

Tuberculosis of the tubes is unusual; it may be either 
primary or secondary. The general appearance is similar 
in both forms. On the surface are numerous scattered 
miliary tubercles, and throughout the walls of the tube are 
minute caseous areas. Dense adhesions are commonly 
formed, and the organs are firmly bound down to neighboring 
structures. This condition may be associated with gonorrheal 
salpingitis. The uterus may become secondarily involved by 
the discharge into it of infected material from the tubes. 

Syphilis is very rare, but has been found in the form of 
gummata and connective-tissue hyperplasia. 

Tumors are not very frequent. Fibroma, myoma, and 
fibromyoma and lipoma have been described. Papilloma 
of the mucous membrane occasionally form and they are 
probably the starting-point of primary carcinoma. Secon- 
dary carcinoma is the result of extension from uterine in- 
volvement. Sarcoma and syncytioma malignum are some- 
times found. 

Cysts of the Fallopian tubes are generally present, as hy- 
drosalpinx, a consequence of obstruction. Small cysts 
attached to a somewhat long and narrow pedicle are known as 
hydatids oj Morgagni. 



EXTRAUTERINE PREGNANCY 

If there is any interference with the entrance of the impreg- 
nated ovum into the uterus an extrauterine development 
takes place. This may be within the ovary, between the 



426 A MANUAL OF PATHOLOGY 

tube and ovary, — tubo-ovarian, — or, what is most common, 
within the tube — a tubal or ectopic pregnancy. 

The chorionic viUi are formed, deciduffi develop, and a 
placenta is evolved. At the same time there is commonly a 
decidua formation within the uterine cavity. As the embryo 
increases in size the walls of the tube become gradually thin- 
ner. By about the third month the tube generally ruptures. 
This may take place within the layers of the broad ligament, 
into the peritoneal cavity, or into the uterus. In any case 
there are severe symptoms of pain and shock and large in- 
ternal hemorrhage occurs. It is very dangerous if the rup- 
ture has taken place at the placental site. Death may result 
from the loss of blood or from a peritonitis. 

If the ovum has died the fetus may degenerate and be- 
come infiltrated with lime salts, forming a lithopedion. 

If the impregnated ovum lodges somewhere on the peri- 
toneum, we have an abdominal pregnancy. A similar con- 
dition is present at times when the ovum has escaped from a 
ruptured tube. In such instances the placenta usually re- 
mains within the tube. Peritonitis commonly ensues, the 
fetus perishes, and a lithopedion may form. 

THE UTERUS 

Congenital malformations are not infrequent and are 
the result of imperfect development of the Miillerian ducts. 
These ducts are two parallel tubes that normally unite in 
their long axis, forming in this way the uterus. There may 
be marked hypoplasia of the uterus and vagina, with very 
imperfect development of the tubes and ovaries. By failure 
of fusion of the ducts the uterus may contain two cavities, and 
if it extends downward divide the vagina into two canals. 

Atresia or stenosis of the os uteri may. l^e either congenital 
or the result of inflammatory conditions. On account of the 
obstruction the uterine cavity may become dilated by the re- 
tention of fluids. If by menstrual discharges is known as 
hejnatometra; by seromucous secretion, hydronietra; if de- 
composition occurs and gas is formed it is then a physometra; 
when pus is present, is a pyometra. 



DISEASES OF THE REPRODUCTIVE SYSTEM 427 

Rupture of the uterus may result from the retention of 
fluid with gradual thinning and degeneration of its walls. 
It generally happens as an accident during pregnancy or 
labor. There may be some diseased condition, particularly 
malignant, of the muscle, or the wall may give way on account 
of too great contraction of its fibers. If the tear does not ex- 
tend all the way through the wall, it is an incomplete rupture; 
is complete whenever the serous covering is involved. The 
condition is associated with shock, and generally very severe 
and frequently fatal hemorrhage. If death does not re- 
sult from the loss of blood, it usually follows from peritonitis. 
Sometimes the wound will cicatrize, the fetus degenerate 
and be discharged through fistulae, and the patient recover. 

In rupture the tear begins, as a rule, just above the cervix 
on the inside and extends in the direction of the fundus. 
If the uterus has been perforated by an instrument, the larger 
opening of the wound is on the outer surface, the opposite 
to what occurs in rupture. 

Malpositions of the Uterus. — Normally the uterus is in a 
position of slight anteflexion and anteversion. The common 
displacements are either forward or backward, as the broad 
ligaments prevent lateral changes. In pathologic anteflexion 
the uterus is greatly flexed or bent, allowing the fundus to 
fall forward and downward. As a result the uterine cavity 
is obstructed and the menstrual fluid retained, giving rise 
to dysmenorrhea. In anteversion the fundus of the uterus 
falls forward and the cervix is displaced backward without 
a change in shape. In retroflexion the uterus is bent back- 
ward at an angle, the fundus falling downward and back- 
ward toward Douglas's pouch. Retroversion refers to a 
bending backward of the uterus without any change in the 
shape of the organ. Although they may occur separately, 
retroflexion and retroversion are generally associated. These 
deformities may be due to pressure from above, from the 
presence of new growths, from tight clothes, or to the presence 
and contraction of inflammatory adhesions. They may also 
be brought about by disease of the uterus itself. 

The uterus may be elevated as a result of the presence of 



428 A MANUAL OF PATHOLOGY 

tumors within the pelvis or of the contraction of adhesions 
dragging the organ upward. The opposite condition, pro- 
lapse of the uterus, or procidentia, is comparatively frequent. 
It is apparently due to a loss of tone in the structures support- 
ing the organ, as in a torn perineum, or to an enlargement of 
the uterus. As it descends the vagina is slowly invaginated. 
x^ccording to the extent of the prolapse three degrees of 
severity may be considered. If the descent is shght and the 
uterus does not leave the pelvis, it is a simple prolapse; if the 
organ is not entirely out of the pelvis, it is a partial prolapse; 
if the uterus has descended to the vulva and discloses the 
vaginal walls, it is a complete prolapse or procidentia. In this 
latter the rectal and vesical walls are also dragged down, 
causing a rectocele and a cystocele. Inversion is a condition 
in which the uterus is more or less completely turned inside 
out. It occurs during labor, from large polyps or from 
localized pressure on the fundus. This condition is often 
accompanied by prolapse. 

Stenosis of the cavity of the uterus may result from 
various inflammations or may be congenital. As a result 
of the blocking of the outlet dilatation of the uterus not in- 
frequently occurs. 

Circulatory Disturbances. — Active hyperemia is nor- 
mally present during menstruation and pregnancy, and is 
similar to what takes place in pathologic conditions. The 
mucous membrane becomes much congested and swollen and 
there is a round-cell infiltration between the glands, which 
are somewhat increased in length. There is probably 
little or no desquamation of the surface epithelium. Serum 
is secreted and this may be hemorrhagic or purulent accord- 
ing to the diapedesis of erythrocytes or the emigration of 
leukocytes. 

Passive hyperemia may be part of a general stasis, but is 
especially marked in severe malpositions or when neoplasms 
press upon the venous plexuses. The uterus is enlarged, 
dilated veins are seen on the outer surface, the mucosa is 
dark red, and the condition generally terminates in a chronic 
hyperplastic endometritis. 



DISEASES OF THE REPRODUCTIVE SYSTEM 429 

Hemorrhage may be normal, as in menstruation, or patho- 
logic. The blood may be within the uterine cavity, in the 
uterine walls, or outside in the peritoneal cavity. When 
the menstrual period is lengthened and more blood than is nor- 
mal is lost, it is known as menorrhagia; if the hemorrhage is 
between the menstrual periods, metrorrhagia. Normally the 
mucous membrane remains intact, but under certain patho- 
logic conditions large masses of endometrium may be dis- 
charged; this is called dysmenorrhea memhranacea. 

In hemorrhage into the peritoneum the blood usually 
collects in Douglas's pouch. It may be derived from a 
ruptured tubal pregnancy, a hematosalpinx, or ruptured 
varicose veins of the broad hgament. The resulting hema- 
toma may be large or small, and it may become absorbed or 
be encapsulated. Inflammation may occur with the forma- 
tion of adhesions between the uterus and rectum. Occasion- 
ally the blood may escape by perforations into the rectum or 
vagina. Death may follow the loss of blood. 

Atrophy occurs normally in old age, or as a consequence 
of the removal of the ovaries. The uterus becomes much 
smaller, dense, and pale, and the blood-vessels show an ob- 
literative arteritis. The endometrium is also greatly re- 
duced in thickness and the greater part of the glands is lost. 

Following childbirth the uterus under normal conditions at 
first rapidly atrophies, then decreases more slowly. By the 
end of the fourth month it has usually regained its normal 
size. This process of involution consists essentially in a 
fatty atrophy of the muscular fibers, which decrease not only 
in size but also in number. 

Hypertrophy may involve the entire uterus, as in the en- 
largement in pregnancy or in chronic congestion and in- 
flammation. Local hypertrophy generally involves the cer- 
vix, which becomes much elongated and may present itself 
at the vulvar orifice. 

Fatty degeneration other than the above is unusual, 
but has been found in typhoid fever, cholera, and in phos- 
phorous poisoning. 

Amyloid degeneration is rare; either the arteries or the 
muscle may be alone involved. 



43° A MANUAL OF PATHOLOGY 

Inflammation of the uterus, if of the outer serous 
surface, is a perimetritis; of the muscular coat, metritis; of 
the hning mucous membrane, endometritis. 

Perimetritis may result from puerperal infection, or be a 
part of a general or local peritonitis. In the acute form there 
may be a layer of pseudomembrane over the uterus and even 
involving neighboring structures. The process soon becomes 
chrome with the formation of adhesions. Parametritis is an 
inflammation of all the structures of the uterus accompanied 
by a celluhtis of the broad hgament and pelvic tissues. 
Usually occurs as a result of puerperal infection. 

Metritis may be acute or chronic. The acute form gener- 
ally occurs during the puerperium, but may be the result of 
gonorrheal infection. The uterus is much enlarged, con- 
gested, soft, and infiltrated with leukocytes. Occasionally 
small abscesses may form. The muscle fibers degenerate, 
thrombosis of the uterine sinuses and veins is quite common,' 
and gangrene sometimes occurs. 

Chronic metritis usually follows the acute form, or is the 
result of delayed involution of the uterus. There is a round- 
cell infiltration along the blood-vessels, the connective tissue 
increases and by contraction causes the muscle-fibers to 
atrophy. The uterus finally becomes small, pale, and dense. 
The entire organ is commonly involved, but occasionally the 
cervical portion is alone affected— it becomes enlarged, con- 
gested, and soft at first but afterward indurated. 

Acute endometritis is usually the result of infection by 
pyogenic organisms or by the gonococcus. It may be found 
m the course of certain infectious diseases, as typhoid fever, 
cholera, scarlet fever, and diphtheria. The mucous mem- 
brane is very hyperemic and swollen, and there is quite ex- 
tensive desquamation of the epithelial cells. Small hemor- 
rhagic areas are seen, and there is a marked mucopurulent 
exudate. There are round-cell infiltration and necrosis of 
the epithehum; the formation of a pseudomembrane may 
occur. In gonorrhea the cervical portion is the usual seat, in 
other infections the fundus. 

Chronic endometritis may follow the acute variety, or result 



DISEASES OF THE REPRODUCTIVE SYSTEM 43 1 

from general debility, local congestion and malnutrition, or 
from the irritation of tumors. 

The mucous membrane is swollen, there is some round-cell 
infiltration and a more or less marked mucopurulent secre- 
tion. As the condition persists there is an increase in either 
the interstitial tissue or the uterine glands. In endometritis 
glandularis the increase in the size and number of the glands 
is the striking feature. The glandular hyperplasia may be so 



m^^ 






r^^3#«-^ 















• ,■■/ 









as?si; ■ ■•■■'f.#^"V 



^im 



Fig. 160. — Chronic Glandular Endometritis. X 40 (Durck). 
Uterine glands greatly jjroliferated, lengthened, and convoluted. 



great as to closely resemble an adenoma. In endometritis 
inter stitialis the glands are much fewer than normal, and 
there is a round-cell infiltration and hyperplasia of the in- 
terglandular connective tissue. 

Atrophy may occur in late stages of chronic endometritis 
and the glands be displaced by connective tissue. In this 
process the openings of the acini, particularly of the Nabothian 



432 A MANUAL OF PATHOLOGY 

glands of the cervix, may become obstructed and give rise 
to small retention cysts. 

Chronic endometritis may give rise to chronic metritis or 
by extension involve the tubes. 

Ulceration or erosion of the cervix is very common, and 
results from endometritis and from lacerations. There is a 
destruction of the superficial epithelium with exposure of the 
deeper tissues. Occasionally there may be a rapid phagedenic 
ulceration with great destruction of tissue extending to the 
bladder and even to the rectum. Has been thought to be 
carcinomatous, but microscopic examinations have been 
negative. 

Lacerations of the cervix result from childbirth; they may 
be simple, double, and multiple or stellate. They are very 
slow in healing and the exposed surfaces become covered by 
granulations. Fibrous connective tissue is usually formed, 
and the part may become very dense and hard. 

Tuberculosis of the uterus is nearly always secondary to 
that of the tubes. The endometrium is usually affected and 
presents either a nodular or a diffuse infiltration. At times 
the endometrium may be completely transformed into a 
caseous mass. 

Syphilis of the uterus is rare, but may occur as a chancre 
upon the cervix or as gummata. 

Tumors. — Fibroids. — These tumors are the most com- 
mon of those of the uterus. Although spoken of as fibroma, 
they nearly always contain a large amount of involuntary 
muscle, so the term fihromyoma is the more correct. They 
occur very frequently in negroes. They are classified ac- 
cording to their situation into: mural, intramural, or inter- 
stitial, when occurring within the muscular body of the uterus; 
submucous, when beneath the endometrium; and subperito- 
neal, when beneath the peritoneal covering. The tumors may 
be single or multiple, and their size varies from a pea to one 
weighing fifty pounds. The largest are the subperitoneal, 
as their growth is practically unlimited. 

The density of the tumors depends upon the amount of 
fibrous tissue present. They are generally encapsulated. 



DISEASES OF THE REPRODUCTIVE SYSTEM 433 

The blood-supply is poor, so degenerations are common. 
These usually begin in the center of the tumor, and the most 
frequent form is calcification. If the tumor has been a 
pedunculated one, the pedicle may become twisted and necro- 
sis set in. Fibromata may be associated with lipoma, 
myxoma, or sarcoma. 

Fibroid tumors, although of the benign type, may give rise 
to severe symptoms on account of exerting pressure upon 
neighboring structures. The submucous type is often 
associated with hyperemia and hemorrhage from the endo- 
metrium or from a degenerated growth. Infection with 
necrosis and gangrene may take place. Labor may also 
be interfered with by the presence of such tumors. 

Sarcoma of the uterus usually originates within the con- 
nective tissue between the muscle-fibers and about the vessels 
or occasionally from the muscle cells — myoma sarcomatodes. 
It may also arise within the submucous tissue. The myome- 
trial sarcoma is generally spindle-cell in character; is grayish- 
white and soft; the endometrial is commonly round celled. 
Angiosarcoma is rare, and the so-called adenosarcoma is 
probably nothing more than an inclusion of the pre-existing 
endometrial glands. 

A peculiar tumor occurring in early life is the edematous 
papillary sarcoma of the cervix. It is composed of a mass 
of soft, grayish, grape-like structures, that microscopically 
are made up of myxomatous round and spindle cells. There 
are also found epithelial tubules, areas of cartilage, and both 
smooth and striated muscle-fibers. Is quite malignant. 

Papilloma appear on the cervix as rather small, cauliflower- 
like growths, composed of connective-tissue villi covered by 
many layers of squamous epithehum. Venereal warts are 
sometimes found upon the cervix. 

Adenoma as such occur as polypoid projections from the 
mucous membrane, or as a glandular hyperplasia of the endo- 
metrium. They are benign. 

Malignant adenoma, or adenocarcinoma, usually arises in 
the fundus of the uterus, upon the posterior wall. It is 
characterized by the tendency of the glands to invade the 
28 



434 A MANUAL OF PATHOLOGY 

uterine muscle and by the epithelium breaking through the 
basement membrane. Quite frequently the epithelium 
proliferates so rapidly that the acini become completely 
filled with cells, the glandular character is lost, and the tumor 
assumes a typical carcinomatous structure. ^letastasis is 
unusual; the destruction is mainly local. The invasion and 
destruction of the muscle progresses until the bladder and the 
rectum may become involved (see Fig. 49). 

Carcinoma is usually an adenocarcinoma and the progress 
is practically similar. There is rapid infiltration with exten- 
sive ulceration. The vaginal walls and the tissues in the 
neighborhood of the cervix become involved. The neighbor- 
ing lymphatic nodes are frequently the seat of metastases. 

Squamous cpithdioma of the cervix is the commonest type 
of malignant tumor. In many cases it probably begins as a 
papilloma. There is soon developed a tendency of the cells 
to infiltrate the surrounding tissues and to grow superficially 
as a cauliflower mass. The growth extends downward, 
involving the vagina; extensive ulceration, accompanied at 
times by severe hemorrhage, occurs, and there is an extremely 
foul discharge. The tumor extends in all directions, and may 
perforate into the bladder or rectum or into the peritoneal 
cavity, giving rise to fatal peritonitis. 

In old people squamous epithelioma may occur in the body 
of the uterus when metaplasia of the columnar epithelium 
has taken place. 

Syncylioma malignum, or chorio-epithelioma, is a pecuhar 
mahgnant tumor developing from embryonal tissue. The 
greater part of the cells are supposed to be derived from the 
syncytium. Is a rare form of growth. 

Cysts of the uterus may result from a liquefaction necrosis 
of a fibromyoma, or from the obstruction of the Nabothian 
follicles. Dermoid cysts are occasionally found. Parasitic 
cysts due to the cysticercus and echinococcus have been des- 
cribed. 

THE VAGINA 

Malformations. — The vagina may be imperforate in its 
entire length or only partially. There may be a septum 



DISEASES OF THE REPRODUCTIVE SYSTEM 435 

dividing the canal in two; such a condition is usually associ- 
ated with a double uterus. Stenosis is seldom congenital; is 
generally secondary to some ulcerative condition. 

When there has been a loss of support, as from a torn 
perineum, there may be a prolapse of the vagina, usually of 
the anterior wall. As the tissues relax the bladder is gradu- 
ally involved; it is dragged downward and appears as a 
bulging of the vaginal wall, — a vaginal cystocele. If the 
posterior wall prolapses and drags in the rectum, it is known 
as a vaginal rectocele. 

Wounds may result from the introduction of foreign bodies, 
from coitus, or from injury during childbirth. If the injury 
or destruction to the part has been severe, fistiilcp may be 
estabhshed between the vagina and neighboring structures. 
Communication between the bladder is known as a vesico- 
vaginal fistula; with the urethra, iirelhrovaginal; with the 
rectum, rectovaginal. Severe secondary inflammations may 
result from infection by urine or feces. 

Inflammation of the vagina, vaginitis or colpitis, may be 
due to injury, as from hot douches, to the presence of foreign 
bodies, to the oxyuris, or to gonorrhea. In mild attacks 
there is a simple catarrhal inflammation, the mucous mem- 
brane becomes reddened, swollen, and covered by a slight 
alkaline mucopurulent secretion. In the gonorrheal form 
the reactions are more severe, the discharge is more purulent, 
and the cervix and urethra are generally involved. Occasion- 
ally when the inflammation is of a very high grade the mucosa 
may be exfoliated, almost as a cast of the vagina. A 
pscudo-mcmhrane miiy he formed in the course of pneumonia, 
pyemia, and other infectious diseases. The mucous surface 
is covered by a dirty grayish pseudo-membrane that is eventu- 
ally cast off, leaving quite extensive ulcerations. This may 
be followed by necrosis of the vaginal walls. 

Chronic vaginitis or Iciikorrhca may follow acute attacks or 
be the result of constitutional disturbances. Is commonly 
known as "the whites," on account of the presence of a thick, 
creamy exudate, acid in reaction. The mucosa is reddened 
and swollen, and resembles the condition seen in acute 



436 A MANUAL OF PATHOLOGY 

vaginitis. The discharge at times is thinner and contains 
less pus. Sometimes there may be marked thickening of 
the vaginal mucosa with very little discharge. 

Tuberculosis of the vagina is secondary to similar dis- 
ease of either the uterus — in which case it appears as rounded 
ulcers — or if of the vulva it is in the form of lupus. 

Syphilis of the vagina is unusual. It may appear as a 
chancre, a mucous patch, or in the form of ulcers. Gummala 
may form and through regeneration give rise to distortion of 
the vagina as the scar-tissue heals. 

Tumors. — Fibromata or fibromyomala are found in the 
submucous and muscular layers as either projecting nodules 
or as polyps. Sarcomata are rare. Papi/lomata are fairly 
common. Carcinoma is usually secondary to cancer of the 
cervix orof the rectum. When primary, is usually of the squa- 
mous epithelioma variety and cauliflower-like in its growth. 

Cysts of the vagina are usually the result of obstructions 
of the follicles. They are generally small and may be single 
or multiple. Some of the larger cysts may develoj) from 
remains of the Wolffian or AlUllerian ducts. May also be 
the result of lymphangiectasis. 

THE VULVA 

Wounds are particularly common as a result of childl)irth. 
They generally occur as lacerations of the posterior fourchcttc 
and may extend not only into the perineum but into the rec- 
tum. If the damage has been very severe, extensive necrosis 
and even gangrene may follow. Severe hemorrhage is also 
not uncommon, forming a hematoma within the labia. If 
comparatively mild infection takes place, abscesses may 
form. 

Hyperemia may be due to acute inflammatory conditions 
or occur as a result of local irritation, as from the oxyuris. Is 
accompanied by increased exudation. Passive hyperemia may 
be a part of a general venous stasis or the result of some local 
obstruction to the outflow of blood. 

Inflammation of the vulva may be the result of many con- 
ditions: uncleanHness, gonorrhea, or injuries. The parts 



DISEASES OF THE REPRODUCTIVE SYSTEM 437 

become reddened, swollen, edematous, and are accompanied 
by a marked exudation that may be mucoid, serous, or puru- 
lent, or any combination of the three. Pseudo-membrane 
may form and gangrene also may occur. Abscesses may be 
due to infection or to extension. 

Noma pudendi is a form of gangrene that occurs spontane- 
ously in debilitated children; it resembles noma of the face. 
Is very rare. 

Tuberculosis, in the form of lupus, is sometimes encoun- 
tered. Occurs as irregular ulcers, with necrotic bases and 
elevated edges. 

Syphilis, usually in the form of a chancre, occurs on the 
vulva. Ulcers of various forms may be present, and mucous 
patches are very common. 

Chancroid is quite frequent; is accompanied by exten- 
sive ulceration and, at times, inguinal buboes. 

Elephantiasis may involve one or both labia, and cause 
a tremendous increase in the size of the part. 

Tumors. — Fibroma and fibromyoma are occasionally 
found projecting from a labium or the clitoris, as polypoid 
tumors. Lipoma, as a polyp from the labium majus, is not 
uncommon. Sarcoma is rare. The caruncle is a small papil- 
lary growth projecting from the urethra, is very vascular, and 
extremely sensitive. Papilioma/a are quite com.mon, and 
occur as hard, flat, or projecting masses; are present in 
syphilis. Cancer is rare, but may arise from the skin, the 
labium majus, or from the glands of Bartholin. Usually 
occurs as a squamous epithelioma, which commonly under- 
goes marked degeneration and ulceration. It extends in all 
directions, and secondarily affects the inguinal glands. 

DISEASES OF THE MAMMARY GLAND 

Malformations. — As an associated condition with imper- 
fect development of the chest-walls one or both glands may 
be absent. They may be hypoplastic, when there is also an 
incomplete development of the sexual organs. A breast may 
be normal in other respects, but be lacking a nipple, or there 
may be several nipples. Supernumerary mamma? — poly- 



438 A MANUAL OF PATHOLOGY 

mastia — may be present in both sexes, usually on the anterior 
surface of the chest and abdomen. They may occur on the 
back or thigh, and occasionally may functionate, although 
they are usually ill developed and lack a nipple. 

Circulatory Disturbances. — Hyperemia is present dur- 
ing menstruation, during pregnancy, and at the beginning of 
lactation. The gland will be reddened, swollen, and some- 
times painful. This congestion may also be brought about 
by some diseased condition of the uterus, the relationship of 
these two organs being very close. 

Hemorrhage is due to some injury of the gland. The 
bleeding may take place within the connective tissue, into 
the glandular structures, or deeper down, behind the gland 
upon the muscle. The blood may escape from the nipple, 
it may be absorbed, or it may become encapsulated by a wall 
of fibrous tissue and form a hematoma. Hemorrhage may 
also be the result of bleeding from the ulcerated surfaces of 
new-growths. 

Inflammation of the mammoe, or mastitis, may rarely be 
due to injury, but it is most commonly the result of infection 
occurring during the puerperium. The micro-organisms 
most frequently gain entrance through fissures of the nipple 
during suckling. Infection directly into the milk-ducts is not 
common. AFaslilis may result from the extension of inflam- 
mations of neighboring structures, as caries of a rib, erysipelas 
of the skin, or in puerperal infection the micro-organisms 
may have been brought to the gland through the blood-ves- 
sels. The disease may be diffuse or involve a portion only of 
the gland, the latter being the more common. In the diffuse 
form the inflammation may extend to neighboring structures, 
setting up a paramastitis. In the circumscribed variety there 
is abscess formation, which may be single or multiple. The 
pus may escape into the milk-ducts and out through the nip- 
ple; it may be interstitial or rupture externally, in the latter 
case frequently causing a fistula. If the pus burrows into the 
deeper tissues, it may perforate into the pleural cavity and 
cause a fatal empyema. Occasionally the pus may be en- 
capsulated, inspissated, and calcified. Sometimes a con- 



DISEASES OF THE REPRODUCTIVE SYSTEM 439 

dition of the mammae similar to that of chronic interstitial 
inflammation of the organs occurs. The glands are firm and 
hard, due to the connective-tissue formation, and small cystic 
dilatations of obstructed milk-ducts may be present. 

Tuberculosis of the mammary glands is rare, except as 
a secondary involvement in tuberculosis of the axillary nodes 
or other tissues. The tubercle bacilli are probably carried 
by the blood. Tubercles are formed which undergo casea- 
tion, and the contents escape into the acini. In this way 
great numbers of the bacilli can gain entrance into the milk. 

Syphilis of the mammae is very rare, but has been seen as 
gummata, which in healing form a dense, stellate scar. 

Atrophy of the glands occurs after the menopause or when 
the ovaries have been removed. 

Hypertrophy at the time of puberty may continue beyond 
the normal limits and cause an enormous development of 
both the glandular and connective -tissue elements of either 
or both breasts. If lactation takes place, the amount of milk 
secreted may be very great. The gland may be much en- 
larged, on account of a diffuse fatty infiltration or lipomatosis. 

Tumors. — Sarcoma is rather infrequent, is usually of the 
round-cell variety, and may be diffuse or in circumscribed 
nodules. One gland alone is generally involved. In the 
diffuse form the mamma rapidly enlarges, the growth infil- 
trates in all directions, the skin soon becomes firmly attached 
and may ulcerate. The structure of the tumor differs in dif- 
ferent parts. It may be quite cystic on account of obstruc- 
tion to the milk-ducts; part may be myxomatous or resemble 
connective-tissue. The sarcoma cells may extend into the 
cystic dilatations as polypoid projections — intracanalicidar 
sarcoma. 

Occasionally the tumors may be circumscribed. They 
most commonly originate within the advcntitia of the milk- 
ducts and nipple, but may arise from any part of the con- 
nective-tissue of the gland. These tumors give metastasis by 
means of the blood, but they are much less malignant than 
the carcinomata. 

Fibroma as a pure connective-tissue tumor is unusual. It 



440 A MANUAL OF PATHOLOGY 

is commonly found in connection with a hyperplasia of the 
glandular structures. 

Adenoma in a typical form is rare, is generally associated 
with an overgrowth of connective-tissue, and is called cither 
adenofibroma or jlhro-adcnoma. According to the relation of 
the glandular and fibrous elements these tumors can be clas- 
silicd into three divisions: 

"Inlcrcanalicular fibro-adenoma, in which the tumor is 
chiefly fibrous in structure, with the ducts and acini irregu- 
larly distributed through it. 

'^Pericanalicular fibro-adcnoma, in which the fibrous tissue 
makes distinct concentric investments of the ducts and groups 
of acini. 

'^ Inlracanalicidar fibro-adenoma, in which polypoid or pap- 
illary growths extend into the ducts." 

These tumors are more or less completely encapsulated, 
and although of the benign type, they not infrequently take 
on a carcinomatous growth. 

Carcinoma is an extremely common tumor of the mam- 
mary gland in women between the ages of forty and fifty. 
About 2 per cent, of cases occur in males. The growth 
usually involves one breast only, and that the right more 
frequently than the left. It develops either from the tubules 
or the acini of the glands, and may start as a carcinoma or 
result from a malignant degeneration of a fibro-adenoma. 
When the growth begins in the acini, it resembles quite closely 
the ordinary racemose character of the gland — is alveolar in 
form. If it is of the tubular type, there are long tubular col- 
lections of cells. 

Although at first the growth may quite closely resemble a 
simple adenoma, proliferative changes soon occur in the epi- 
thelium. The cells, instead of forming a single layer, increase 
in number and lose their resemblance to the normal structure. 
These new-formed cells may completely fill the acini, or they 
may be found within the surrounding tissue as a result of 
destruction of the basement membrane. 

According to the relationship between stroma and paren- 
chyma mammary carcinoma maybe divided into three classes: 



DISEASES OF THE REPRODUCTIVE SYSTEM 441 

Carcinoma simplex, in which there is, relatively speaking, 



M 






?llp§ 




'■'■'^^^'i/x'-'y-- ■ '■• 


■??m^-<'-'. 


0$$5:-,::' 


,;v>%.;;:.y 


'■■''/. wt'i^N^;;-;::"'-' 


'. ,'\_," "'o.' ■.■•'■ 


.' ' '.'■ \- • ~'.t"-'.'.''. '.~ ." 


■'- ."'■■/."."•-■. '. .• 



Fig. 161. 



. ■ ;|^:^' i^^§m^i§^'-- ■■ ■ >. 



\/.:,i^-v/.- .■:,,^-,. •.:,-; • -^'v:^••^V:^• 
j:;:V,--^::v.;:;;:,-,.:;:^^:^;y; 

Fir,. 162. 




Fig. 163. 

Fig. 161, Intercanalicular adcnofibroma of mamma. The fibro-con- 
nective tissue bears no definite relation to the glandular canals. Fig. 162, 
Pericanalicular adenofibroma of mamma. The fibro-connective tissue 
shows a peculiar concentric relation to the glandular canals. Fig. 163, 
Intracanalicular adenofibroma of mamma. Pa|)illary connective-tissue 
growths project into the glandular canals (McFarland). 

an equal amount of connective-tissue and epithelial cells. 



i 



442 A MANUAL OF PATHOLOGY 

Is less malignant than the medullary, but more so than the 
scirrhous. 

Encephaloid or medullary carcinoma, which is very rich in 
cells and poor in stroma, is soft, contains much "cancer 
juice," and hemorrhages are not uncommon. It grows rap- 
idly, soon ulcerates, and is rapidly fatal. 

Scirrhous carcinoma is characterized by a great preponder- 
ance of connective tissue, is hard, is slow in growth, does not 
tend to give metastases, and is slowly fatal. In this form 
there is frequently a retraction of the nipple. 

The so-called colloid carcinoma of the breast is generally 
one in which a mvxomatous degeneration of the connective 
tissue has given rise to the appearance. 

Extension of carcinoma may take place directly to the skin 
or, by penetrating deeply, enter the chest-walls and pleura?. 
Metastasis is common, takes place early, and may be very 
extensive, the axillary nodes being first involved. Secondary 
growths may also occur in distant parts of the body. 

Pagers disease begins as a chronic eczema of the nipple and 
adjacent skin. It may have existed for ten or fifteen years 
with more or less complete destruction of the nipple, and then -J 
take on a carcinomatous change. ■ 

Cysts are quite commonly found, particularly in new- 
growths in which there has been an attempt at secretion with- 
out any outlet. Small milk-cysts may result from obstruction 
to the ducts. The contents of the cysts may be milky, or, 
through absorption of the liquid portion, become thick and 
caseous. 



CHAPTER XXIV 

DISEASES OF THE MOTOR SYSTEM 
BONES 

Circulatory Disturbances. — Hyperemia is usually asso- 
ciated with inflammatory disturbances of adjacent tissues. 
The periosteum is reddened and swollen, and the marrow is 
bluish-red in color. 

Thrombosis may occur in the nutrient blood-vessels as a 
result of fracture or disease, but seldom causes any distur- 
bances on account of the rich anastomoses. Embolism may 
occur, but seldom causes trouble. 

Hemorrhage takes place as a result of injury to the perios- 
teum or the bone itself, as in fracture. Is generally soon 
absorbed, but if it becomes infected, suppuration may follow. 
Necrosis may at times be caused by the blood dissecting the 
periosteum away from the bone. 

Rachitis. — Rickets is a constitutional disorder in which 
there are nutritional disturbances involving, to a greater or 
lesser extent, all the bones of the skeleton. The long bones 
become shortened, thickened, and twisted, and there is a lack 
of calcium salts. It makes its appearance most frequently 
in the first or second years of life, but may be delayed until 
several years later. The cause is not known, but it evidently 
depends upon poor hygiene and malnutrition, consequently 
it is more common among the poorer classes. 

The head has a peculiar square shape and is large in pro- 
portion to the body. In infants the anterior fontanel may 
persist for three or four years, and the bones of the skull may 
contain localized areas in which there is a lack of mineral 
salts — craniolabes. The chest is usually prominent, coming 
to a distinct angle — "pigeon-breast" — and the anterior ends 
of the ribs at the junction with the cartilage are distinctly 

443 



444 A MANUAL OF PATHOLOGY 

enlarged, forming the rachitic rosary. If the disease is severe, 
there may be involvement of the spinal column. If the cur- 
vature is forward, lordosis; if backward, kyphosis; sideways, 
scoliosis. These curvatures may occur in combination. The 
pelvis may show changes that have a direct influence upon 
childbirth; it is distinctly flattened. The anteroposterior 
diameter is decreased, while the transverse is increased. The 
tibicT and fibulae are usually much curved outwardly, the 
femur anteriorly. The lesions are most marked at the ex- 
tremities of the long bones. Microscopically there is seen 
at the extremities an irregular bone-formation with a defi- 
ciency of lime salts in many areas, while neighboring portions 
will show ossification. The normal laminated appearance 
is absent. 

The marrow is of the red variety, similar to that in the fetus, 
being rich in cells. The increase in size of the heads of the 
long bones is due to an increase of the cartilage cells and en- 
larged marrow-spaces. Associated with the lesions of the 
bones are gastrointestinal disorders and fibrous hyperplasia 
in both spleen and liver. There are a decrease in the ery- 
throcytes and an increase in the leukocytes. 

Osteomalacia is a condition of softening and flexibihty of 
the bone following absorption of the bone salts. It is most 
common in women of the poorer classes, and frequently 
appears in connection with pregnancy. It is more common 
in certain regions — along the Rhine and in central Germany — 
than elsewhere. As a result of the flexibility of the bones, 
fractures are very common and all varieties of deformities may 
appear. The pelvis is often the seat of a typical deformity. 
As a result of the pressure of the spinal column from above 
and from the femurs below, the pubes are pushed upward and 
forward like a beak, the sides of the pelvis inward, and the 
iliac crests outward. From above, the opening in such a pelvis 
is triangular. Microscopically it is seen that the loss of bone 
salts takes place first at the periphery and extends toward the 
center. The laminated condition remains unchanged until 
late in the disease, and the marrow is red. Where the bones 
are much bent or there has been a fracture, the regular histo- 



DISEASES OF THE MOTOR SYSTEM 445 

logic Structure is not retained. The bones are soft and easily 
broken or cut. Cachexia appears eventually, and the patient 
usually dies from exhaustion following repeated fractures or 
from some intercurrent disease. 

Atrophy of the bones occurs constantly, but regeneration 
continues also. In various conditions the destruction is too 
rapid and actual atrophy takes place — either general or local. 
Local atrophy is usually the result of pressure causing ob- 
struction of the periosteal blood-vessels, thus interfering with 
the nutrition of the bone. When the bones become very brit- 
tle as a result of atrophy, the condition is known as jragilitas 
OS slum. 

Hypertrophy may be general or local, the latter being due 
to increased work brought upon certain areas of muscular 
attachment. General enlargement seems to be due to various 
nerve disturbances, and is frequently associated with lesions 
of the pituitary body, as in a akromegaly. 

Inflammation may involve the covering of the bone, — 
periostitis, — the bone \isQ\i,— ostitis, — or the marrow — osteo- 
myelitis. It is due to traumatism and infection. 

Periostitis may be acute or chronic. In the simple or acute 
form the periosteum becomes swollen, hyperemic, and infil- 
trated with blood. The process may stop there, but if infec- 
tion has taken place, there is generally the formation of an 
abscess beneath the periosteum. In such a case the nutrition 
of the bone is interfered with, and the osseous tissue begins 
to undergo destruction — necrosis. Large portions may sep- 
arate and be discharged as sequestra through a superficial 
opening. The process may extend into and involve the mar- 
row cavity, and death may result from septicemia or pyemia. 
The so-called malignant periostitis is merely a very severe 
purulent periostitis of considerable extent, and accompanied 
by marked destruction of the bone. 

Chronic periostitis may have originated as such, or it may 
have followed an acute form. It may be fibrous, in which the 
periosteum becomes very greatly thickened and adheres very 
closely to the bone. Ossifying periostitis is a condition in 
which there is the formation of loose bony tissue beneath the 



446 A MANUAL OF PATHOLOGY 

periosteum. It is found in pregnancy, in tumors, and in 
syphilis and tuberculosis of the bones. 

Bony excrescences, as exostoses and osteophytes, may form 
and the surrounding connective tissue may become involved — 
par ostitis. 

Osteitis and osteomyelitis have to be considered together, as 
the two conditions do not exist separately. This condition re- 
sults from infection, either by micro-organisms from the blood, 
from local infections, or from a pre-existing periostitis. The 
inflammation generally starts in the medullary cavity of the 
long bones, the marrow of which is much congested at first 
and dark red in color. Later there is a cellular infiltration, 
and finally suppuration occurs, the pus being localized or in 
streaks. The surrounding bone becomes involved, and more 
or less extensive necrosis follows. The periosteum becomes 
inflamed, and the suppuration may extend to and involve 
the epiphyses. The necrotic portion may remain as a seques- 
trum, being surrounded by a layer of normal bone. As long 
as the sequestrum remains, healing will not take place, but 
when it is removed, either entire or by absorption, new bone 
is formed and there is a return to nearly the normal. When 
the condition terminates fatally, it is generally due to pyemia. 

Chronic osteomyelitis generally is a condition following the 
acute form as a result of a retained sequestrum. The changes 
in this disease arc more marked in the bone than in the mar- 
row^ There are two varieties of the chronic form: osteopo- 
rosis, in which absorption takes place with an increase in the 
size of the Haversian spaces. The bone becomes more 
spongy, and the enlarged spaces become filled w^ith marrow; 
osteosclerosis, in which there is an increased formation of bone, 
particularly beneath the periosteum, but also within the mar- 
row cavity. The subperiosteal deposit may be very dense 
and possess an ivory-like eburnation. 

Necrosis refers to the destruction of large portions of bone, 
as a result of interference with the blood-supply or from the 
extension of disease from the periosteum or neighboring bone. 

The dead piece remains as a sequestrum; part having been 
absorbed, the rest remains in a cavity surrounded by granula- 



DISEASES OF THE MOTOR SYSTEM 447 

tion tissue and pus. It acts as a foreign body, and constantly 
keeps up a suppurative reaction in the adjacent structures. 
A fistulous opening or cloaca, communicating with the exte- 
rior, generally forms, and the pus continues to discharge 
through it. This may continue for years if the sequestrum 
is so large that it cannot pass through the opening. When it 
does escape or become absorbed, heahng takes place. Phos- 
phorous necrosis of the maxillae is frequently observed in 
those who are employed in the manufacture of phosphorous 
matches. The process begins as a thickening of the perios- 
teum, with suppuration, caries, and necrosis, which may be 
VQry widespread and destructive. The condition is favored 
by the presence of carious teeth. 

Tuberculosis of the bones is most frequent in childhood 
and may begin during uterine life. The epiphyses of the long 
bones are most commonly involved, then the spinal column, 
the wrist- and the ankle-joints. The infection may be hem- 
atogenous from tuberculosis of other organs, or it may result 
from direct extension by contiguity. The disease may occur 
in a miliary form within the bone-marrow, or as a locahzed 
condition of the periosteum. The process extends more 
rapidly in the spongy bone and frequently involves the joints. 

In the marrow cavities of the bone tubercles appear as 
small grayish areas surrounded by a zone of active hyperemia. 
These extend through the Haversian canals, involving com- 
pact as well as spongy layers. These areas undergo casea- 
tion and are accompanied by caries of the bones. The degen- 
erated masses may so obstruct the blood-supply as to cause 
necrosis. As the bone is destroyed, broken-down masses 
are formed, and these may escape into the surrounding tissue, 
giving rise to a cold abscess. There is little inflammatory 
reaction; the degenerated tissue follows along the lines of 
least resistance, along muscle-sheaths, and may finally be 
evacuated at some distance from the seat of the disease. 
This is particularly common in Pott's disease, tubercular 
caries of the spine. Occasionally encapsulation and absorp- 
tion take place, but this is unusual. The periosteum sur- 
rounding the degenerated area may undergo a marked new 
bone-formation. 



448 A MANUAL OF PATHOLOGY 

Very extensive deformities may ensue in this disease, either 
as a result of destruction of the bone or from the formation of 
osteopyhtes. 

In long-continued tubercular degeneration of the bone 
extensive amyloid changes in the internal organs are common. 

Syphilis of the bones may be either hereditary or acquired. 

In congenital or hereditary syphilis the epiphyseal function 
is marked by a narrow whitish or reddish-white hne extend- 
ing through the bone. The cartilage at this point is much 
thickened, and the calcified portions project irregularly into 
the marrow cavity. As the condition progresses the cartilage 
may become almost gelatinous, and finally there may form a 
distinct, irregular, yellowish hne of granulation tissue sepa- 
rating the diaphysis and the cartilage. This is one of the 
characteristic signs of congenital syphilis. 

Acquired syphilis generally involves the periosteum and 
occurs usually in the tertiary stage. It may appear as a peri- 
ostitis of the skull, tibia, ulna, etc., with thickening due to 
hyperplasia. This may become gummatous, set up a super- 
ficial erosion and necrosis of adjacent bones, with quite 
extensive loss of tissue. This is not infrequent in the skull. 

Leprosy generally begins in the marrow in the form of 
nodules, and sets up an osteomyelitis. In one form, lepra 
mutilans, there may be marked destruction and absorption of 
the phalanges. 

Actinomycosis gives rise to an osteomyelitis with more or 
less caries and necrosis. 

Tumors. — The periosteum may be the seat of a fibroma, a 
myxoma, or a lipoma. Chondromata also develop from the 
periosteum, are most common on the extremities, and are 
generally multiple. The osteomata are tumors formed of 
bone. 

Sarcoma is the most frequent and the most important bone 
tumor, being also the only primary mahgnant growth. Any 
of the various forms may occur, the spindle-cell and the 
giant-cell being the most common, but round-cell, pig- 
mented, and angiosarcoma are occasionally seen. The tumor 
may originate from the periosteum, the bone-marrow, or the 



DISEASES OF THE MOTOR SYSTEM 449 

bone. The giant-cell sarcoma, or epulis, is found upon the 
lower jaw, is usually only slightly malignant; may last for 
years and not give metastases. When the growth originates 
within the medulla, the bone gradually becomes much 
thinned and may break, allowing the tumor-cells to escape. 
An osteoid sarcoma is one generally arising from the perios- 
teum at the ends of the long bones, and is characterized by the 
formation within it of irregular masses of bone. 

Secondary infection may give rise to a general sarcomatosis 
of the bony structures. 

Chloroma is a form of sarcoma that is green or yellow in 
color, and is usually found in parts of the skull. 

Carcinoma probably never occurs except as a secondary 
involvement, particularly in cases of carcinoma of the breast, 
thyroid gland, and prostate. 

Fractures. — A fracture is a solution in the continuity of a 
bone, and is usually due to traumatism or to muscular con- 
traction. The break may occur in any direction in the bone 
— transverse, oblique, or parallel to the long axis, or any mod- 
ification. If the break is not complete of all fibers, it is known 
as a green-stick fracture; this is common in children. If 
there are several fragments it is called a comminuted jractiire. 
If an opening to the surface is made, it is a compound fracture. 

When a bone is broken, reparative processes take place and 
the bone is regenerated. After the fracture there is an extrav- 
asation of blood between the fragments. Proliferation of the 
cells of the periosteum occur, and calcareous matter is depos- 
ited, forming cartilage, or callus. This is slowly converted into 
bony tissue. At first there is an excess of it, but all except 
that immediately surrounding the fracture is absorbed. The 
callus is derived from the periosteum and from the medullary 
cavity. At the time of its formation new blood-vessels appear 
to assist in the nutrition. More or less deformity may accom- 
pany the process of repair, according to whether or not the 
broken fragments were carefully approximated. 



29 



450 A MANUAL OF PATHOLOGY 

DISEASES OF THE JOINTS 

Luxation is a condition in which the articulating surfaces 
are disturbed in their relations. It is due to traumatism, and 
when it occurs, there is generally a rupture of some of the liga- 
ments with laceration of the adjacent soft parts. If the sur- 
faces are restored to their normal position, inflammatory 
reaction takes place, the capsule and the ligaments heal, and 
a normal condition supervenes. If restoration has been in- 
complete or only partial, absorption of the' end of the bone 
occurs, the periosteum undergoes calcification, and a new 
joint may be formed. Fibrous tissue, cartilage, or bone may, 
however, form, and bind the joint so closely that no motion is 
preserved ; this condition is called ankylosis. 

Hyperemia of the joints is found after injuries, in mild 
inflammations, and in rheumatic conditions. The synovial 
membranes are mainly affected. They are pinkish, swollen, 
and the synovial fluid is both increased in amount and more 
watery than normal. 

Hemorrhage generally follows an injury, but may occur 
in inflammations and in the course of hemorrhagic diseases. 
It is called hcmarthrosis. If infection does not occur, absorp- 
tion slowly takes place, leaving the tissues considerably pig- 
mented. 

Arthritis, or inflammation of a joint, may be due to an 
injury or to a hematogenous infection in certain diseases, as 
scarlet fever, pyemia, or gonorrhea. The synovial mem- 
branes are chiefly involved, the cartilages less so and secon- 
darily. If all the structures of the joints are involved, it is a 
panarthritis. The exudation into the joint may be serous, 
fibrinous, or purulent, and the after-results depend mainly 
upon which variety of arthritis existed. If serous, the fluid is 
generally soon absorbed and the joint returns to a normal 
condition. If, however, there is a serofibrinous exudation, 
the process will probably continue longer and adhesions form 
within the joint. The most serious variety is the purulent. 
The entire joint is frequently attacked, the synovial mem- 
brane swollen and hyperemic, and the surface covered by pus- 



DISEASES OF THE MOTOR SYSTEM 45 1 

cells and fibrin. The joint contains a greater or less amount 
of pus, and the articulating cartilages may be eroded and even 
necrotic, with involvement of the neighboring bone. 

Any of the above varieties may become chronic, and in the 
serous form a hydrarthrosis^ or collection of fluid in the joint, 
may be present. In the purulent variety, as a result of the 
destruction of cartilage or bone, the joint may lose all power 
of motion — ankylosis — from the formation of ' fibrous and 
bony adhesions. 

Acute articular rheumatism is a condition in which one 
or more joints are acutely inflamed and painful. This 
process is generally considered to be the result of infection; 
staphylococci, gonococci, and other organisms have been 
recovered from the affected joints. The joints are swollen, 
red, and painful, and the surfaces arc covered more or less by 
masses of fibrin, some of which may be suspended in the 
exudate. There are seldom many leukocytes present. As 
a result of the inflammation, either fibrous or bony ankylosis 
generally occurs, with more or less subsequent deformity. 

Arthritis deformans, or rheumatoid arthritis, is a chronic 
process occurring, as a rule, in people past middle hfe. There 
is J. proliferation of cartilage cells, and finally softenin g, with 
ulceration ot the superficial cclls. This gradually extends 
down to the bone, the surface ot \vhich frequently shows some 
absorption. At the edge of the joint exostoses may form. 
The ligaments become contracted and fibrous, and ankvlosj s 
occurs?" As a result of the des truct ion of bone and formation 
of connective tissue, all varieties ot"subluxationsT partTal dislo- 
cation) and deformities occur. " * 

The joints most commonly involved are those of the hip 
and knee, metacarpo-phalangeal articulations of the hand, 
and the corresponding ones of the feet. 

Senile arthritis resembles very closely the former variety, 
except that it is more widespread, involving the hip, shoulder, 
and elbow, and occurs in old people. 

Neuropathic arthritis occurs in spinal diseases, particu- 
larly posterior sclerosis, syringomyelia, and transverse mye- 
litis. The joints of the lower extremities are more commonly 



452 A MANUAL OF PATHOLOGY 

involved. The lesions closely resemble those of arthritis 
deformans, but there is seldom much pain. 

Arthritis uratica, or gout, is a condition in which there 
are deposits of urates within the joints and the adjacent 
connective tissues. It generally affects the smaller joints of 
the hands and feet, particularly the metatarso-phalangeal 
articulation of the great toe. The joint becomes red, swollen, 
and very painful; there is a serous effusion into it, and the 
salts are precipitated from this fluid. These substances may 
form quite large, chalky deposits. After repeated attacks 
chronic changes may occur within the joint, such as softening 
and erosions of the cartilage, hyperplasia of the periosteum, 
with some ossification. Besides the local conditions, there are 
constitutional disturbances and also widespread tissue 
changes, particularly atheroma of the blood-vessels. 

Tuberculosis of the joints is most common in childhood, 
and may be primary or secondary. It occurs most frequently 
in the hip, knee, and spine, although any joint may be 
attacked. In the primary form the synovial meml)ranes are 
first involved. The secondary variety generally results from 
extension from tuberculosis of the bone. 

In the synovial membrane are found extensive soft granu- 
lations in which are seen small yellowish or gray tubercles. 
Caseous degeneration appears early, as a rule, and the joint 
may be filled with broken-down tissue forming a cold abscess. 
When the process has extended from the bone, there is 
marked destruction of tissue around as well as within the 
joint. The abscess contents may burrow, and emptying ui)on 
the surface form a sinus. 

Death may result from associated amyloid disease or 
exhaustion. 

If the process subsides, the joint is usually ankylosed in 
an abnormal position. 

Syphilis of the joints is found in children as a congenital 
lesion. There are thickenings of the ligaments, ulceration 
of the cartilages, and a purulent exudation. Occasionally 
gummata may be present. In adults, as a result of acquired 
syphilis, there may be a serous or sero-fibrinous inflamma- 



DISEASES OF THE MOTOR SYSTEM 453 

tion of the joint. Gummata sometimes occur, and as a 
result of degeneration with fibrous formation may cause 
lesions similar to arthritis deformans. 

Tumors. — The synovial fringes may show small lipomata 
and fibromata. These may become separated and lie free 
within the joint, the so-called "rice bodies," which are small 
structures originating from the villi of the synovial mem- 
brane; are generally quite numerous, thirty or forty being 
found at times. The joints may be secondarily involved by 
new-growths in adjacent tissues. 

DISEASES OF THE TENDONS AND BURSiE 

Tenosynovitis refers to an inflammation of the sheath of [ 

a tendon and may be acute or chronic, or serous, fibrinous, '' 

or purulent, or any combination, according to the exudate. 
The purulent is usually the result of a secondary infection. 

Bursitis, inflammation of the bursa, is usually found in 
the prepatellar bursa as a result of chronic irritation, and is 
accompanied by effusion. 

Tuberculosis may involve either of the above structures 
secondarily to disease of the bones and joints. 

DISEASES OF THE VOLUNTARY MUSCLES 

Circulatory Disturbances. — Anemia may be part of a 
general condition or the result of local interference. Degen- 
erations of the muscle occur if the anemia has been suffi- 
ciently severe or long continued. 

Hyperemia occurs during exercise and in inflammatory 
processes. 

Hemorrhage results from injuries or from the rupture of a 
blood-vessel that is either diseased or in which the blood- 
l^rcssurc has been too great. 

Degenerations. — Neerosis of muscle-fibers may follow 
injuries, burns, and various local causes; the tissue becoming 
blackish in color and disappearing. 

Cloudy swelling is found in infectious and toxic conditions- 
in general and in the neighborhood of inflammatory changes 
and tumors. The sarcoplasm becomes very granular and 



454 A MANUAL OF PATHOLOGY 

the striations disappear. Fatty degeneration frequently fol- 
lows. 

Fatty metamor pilosis follows the cloudy swelling when the 
original cause has been very harmful, as in phosphorous and 
arsenic poisoning. The muscles are flabby and yellowish in 
color. The fibers lose their striations and become filled with 
fat-drops. 

Fatty infiltration consists of the deposit of fat between the 
muscle-fibers. It is most typical in pseudo hypertrophic mus- 
cular atrophy, but may be present to some extent in obesity. 

Amyloid degeneration is rare in voluntary muscles, but 
occurs occasionally in the non-striated. 

Calcification occurs in the form of ossifying myositis. 

Hyaline Degeneration. — In this the muscle-fibers become 
granular and cloudy, and the transverse striations are ob- 
scured. The hyaline change appears in streaks, the fibers 
having become transformed into a homogeneous mass within 
the sarcolemma. The fibers break in two, and rupture of 
the muscle may occur. This degeneration is found in the 
course of infectious conditions, as typhoid fever and small- 
pox. It is found usually in the rectus abdominis, in the long 
muscles of the thigh, in the diaphragm, and in the heart. 

Atrophy. — Simple atrophy is usually either senile or the 
result of inaction. The fibers become smaller, and there is 
usually some hyperplasia of the connective tissue. Brown 
atrophy is quite common as a senile change. In it brown pig- 
ment particles are deposited in the muscle-fibers near the 
nuclei, and impart a brown color to the tissue. 

Progressive muscular atrophy usually involves the 
muscles of the hands, arms, and shoulders, but may attack 
those of the diaphragm and back. The muscles are pale 
and flabby, and show various degenerations, such as trans- 
verse division, longitudinal separation, coagulation necrosis, 
and vacuolation. At the same time there is a connective- 
tissue hyperplasia. 

Pseudohypertrophic muscular atrophy commonly 
makes its appearance in the muscles of the calf, thigh, and 
upper extremities. The muscles are much larger than nor- 



DISEASES OF THE MOTOR SYSTEM 455 

mal, but are soft and flabby. Microscopically there is seen a 
great hypertrophy of the intermuscular connective tissue, 
with fatty infiltration and atrophy of the fibers. 

Many of the muscular atrophies depend upon various 
obscure nerve lesions, as such changes are found in syringo- 
myelia; acute anterior poliomyelitis; lateral scleroses; in 
degenerations of the peripheral nerves; in diseases of the 
anterior nerve- roots; in diseases of the pons, and possibly of 
the nerve-endings. 

Inflammation or myositis is generally the result of 
inflammatory changes in adjacent tissues. It may be acute 
or chronic, local or disseminated. 

The process is usually not severe; the muscle is swollen, 
reddened, and there is a slight exudation, as well as a round- 
cell infiltration. Some of the fibers may degenerate. 

Hemorrhagic myositis is characterized by marked hemor- 
rhagic infiltration into the muscle. It may follow extension 
from gangrenous processes near by. 

Purulent myositis is characterized by local or disseminated 
abscess formations, with necroses and breaking-down of the 
tissues. It is clue to infection by micro-organisms as a result 
of traumatism through conveyance by the blood or lymph- 
atics or to infectious emboli. In the healing, masses of 
connective tissue may form and occasion more or less severe 
deformities, due to shortening. Sometimes an abscess may 
become encapsulated and calcified. 

Acute disseminated polymyositis is a condition in which 
many muscles are simultaneously affected. It is of infectious 
origin. There is round-cell infiltration between the fibers, 
many of which show degenerative changes. 

Chronic myositis may be a slow process, found in tubercu- 
losis and actinomycosis, in which there is long-continued 
suppuration without fibrosis. The ordinary form is the 
myositis fibrosa, in which there is a slow increase in the 
amount of connective tissue with degeneration and atrophy 
of the muscle-fibers. It follows acute myositis and some- 
times after certain nerve-lesions. 

Myositis ossificans is a chronic inflammatory condition in 



456 A MANUAL OF PATHOLOGY 

which there is actual bone-formation within the intermus- 
cular connective tissue, in fascia, and tendons. It is found 
in the deltoid, pectoral, and adductor muscles, and appears 
to be the result of long-continued and repeated shght injuries. 

Myositis ossificans progressiva is a peculiar condition begin- 
ning in the muscles of the back of the neck. The ossify- 
ing process gradually extends to other muscles of the trunk. 
The deposit of bone may become very great and cause marked 
interference with muscular contraction. 

Tuberculosis of the muscle is commonly secondary to le- 
sions in adjacent tissue, and appears either in the form of 
caseous degeneration, cold abscess, or of fibrous formation. 
Hematogenic infection is uncommon in general miliary tuber- 
culosis, but may occur. 

Syphilis is rare, but may be found in the form of gummata, 
or as a diffuse hyperplasia of the muscular septa, with atrophy 
of the muscle-fibers. The muscles usually involved are the 
biceps, masseter, tongue, and back. 

Glanders and actinomycosis may involve the muscles 
by extension. 

Tumors, as a rule, originate within the intermuscular 
connective tissue and may be any one of that type — lipoma, 
fibroma, etc. The sarcoma is not infrequent in any of its 
combinations, and may be spindle- or round-celled in type. 
Carcinoma is always secondary, and is found in the neighbor- 
hood of similar growths in the mamma?, stomach, skin, etc., 
as a diffuse infiltration. 

Parasites are not uncommon, the most frequent being the 
Trichina spiralis, the Cyslicercus cellulosce, and the Tcenia 
echinococcus. 






CHAPTER XXV 
THE DUCTLESS GLANDS 

THE THYROID 

Malformation. — It may be congenitally absent, varia- 
tions in size are common, and small accessory glands may 
occur. Total absence is usually associated with cretinism 
or idiocy. 

Atrophy takes place normally in old age. 

Hypertrophy^ or goitre^ is a condition in which there is 
hyperplasia of the interstitial and glandular tissues. These 
enlargements are classified under various headings. 

Graves^ or Basedow^ s disease, exophthalmic goitre, is an en- 
largement of the gland associated with certain cardiac and 
eye symptoms. The blood-vessels are dilated, interstitial 
hemorrhages may occur, and these are sometimes followed 
by necrosis. There is a proliferation of the epithelium of 
the acini with a decrease of the colloid material. The 
symptoms may be due lo an excess of iodin formation. 

Parenchymatous goitre consists of an accumulation of secre- 
tion within the acini which have undergone hyperplasia. 
The enlargement may be uniform or nodular. 

Cystic goitre is a variety of the above in which the walls 
separating the acini have atrophied and allowed large accu- 
mulations of colloid material to form (Fig. lo). 

Fibrous goitre is one in which there has been a great 
increase in the connective tissue. The growth is slow, and 
the resulting tumor is very hard, dense, and at times calci- 
fied. Hyaline degeneration of the connective tissue and 
blood-vessels frequently occurs. 

Adenomatous goitre is one in which there has been a dis- 
tinct increase in the number of the alveoli. It resembles 
an adenoma except that the growth is not circumscribed. 

457 



mm^^ 



458 A I^JPIUAL OF PATHOLOGY 

The effects of goitre may be local, as a result of the pressure 
exerted, or distant, on account of some disturbance of 
nutrition. Its cause is unknown. In certain countries it is 
endemic, and more common in high altitudes than in low. 

It is very commonly associated with cretinism, occurring 
in about 60 per cent, of such cases. 

Hyperemia occurs in cardiac disease and when there is 
obstruction to the circulation by tumors. In Graves' dis- 
ease the gland is very vascular. 

Inflammation (thyroiditis) is not common. It may 
follow traumatism or infection, and varies in its severity. 
Suppuration may occur with, at times, fatal results. The 
pus may remain confined within the capsule, and by pressure 
interfere with respiration. The abscess may perforate the 
trachea, esophagus, or skin, or it may follow along the cer- 
vical fascia into the mediastinum. 

Tuberculosis, syphilis, and actinomycosis are very 
unusual, but have been observed. 

Tumors. — Fibromata in the form of circumscribed no- 
dules occasionally occur. 

Sarcoma is a common primary tumor of the gland. It 
occurs in all forms, the round-cell variety being the com- 
monest. 

Carcinoma is the commonest form of primary tumor. It 
begins usually in an adenomatous goitre, and is of the adeno- 
carcinomatous type. It grows rapidly, soon invades the 
tissues of the neck, and frequently gives metastases. Degen- 
erative changes are quite common. 

Adenoma can seldom be differentiated from a glandular 
hyperplasia unless the growth is distinctly circumscribed. 

THE ADRENALS 

Malformation. — They are seldom absent, but may be 
unusually small. Supplementary adrenals are not uncom- 
mon, and inclosure of fragments in the liver, kidney, and 
genital organs is quite frequent. These may give rise to 
hyperncphromata. 

Fatty degeneration is quite common. The gland is 



THE DUCTLESS GlJ^DS 459 

yellowish and soft. The medullary portion mainly is involved, 
the cortex remaining as a thin wall. On account of post- 
mortem changes taking place so rapidly, it is at times very 
difficult to accurately judge the importance of the lesion. 

Amyloid changes occur in the blood-vessels as a part of 
general amyloid disease. 

Pigmentation is present in senility. The cortex con- 
tains fine yellowish granules. 

Hemorrhage sometimes occurs either as a result of injury 
or of constitutional conditions. The blood may be absorbed 
or encysted, with induration and calcification. 

Syphilis occasionally occurs, either as a gumma or an 
induration. 

Tuberculosis of the adrenals is not uncommon. It is 
frequently a part of a general miliary involvement. 

Primary fubcrculosis, in the form of a caseous degenera- 
tion, is the lesion most generally associated with Addison's 
disease. The adrenals are enlarged, nodular, and the cap- 
sule is thickened. Caseous areas and small cavities filled 
with a thick, curdy pus are frequently found. Calcification 
may take place. 

Tumors. — Sarcoma, adenoma, and carcinoma may occur 
as primary growths, and are not infrequently associated 
with Addison's disease. As secondary growths they are 
more common. 

THE SPLEEN 

Malformations. — Total absence may occur. It may be 
divided into lobes, and accessory or supernumerary spleens 
of small size are quite common. 

The organ may be unusually movable. It may be much 
displaced by pressure from neighboring organs or collections 
of fluids. 

Anemia may be part of a general condition or follow 
severe hemorrhage. The organ is smaller than normal, pale, 
and the capsule is much wrinkled. On section, the stroma 
is prominent and the color is a reddish-gray or slate. 

Hyperemia. — Active hyperemia is physiologic after a 



460 A MANUAL OF PATHOLOGY 

large meal, and is almost constantly present in the infectious 
fevers. The spleen may be several times its normal size, 
is dark red in color, and the capsule is greatly stretched 
and the pulp so very soft, almost semifluid, that it oozes 
from the cut surface. If the condition is acute, the swelling 
is due to the hyperemia. If long continued, the connective 
tissue may increase in both the trabeculae and the capsule. 

This active hyperemia is especially common in typhoid 
fever, and the micro-organisms can usually be recovered 
from the spleen. 

Passive hyperemia is due to obstruction of the circulation, 
as in cirrhosis of the liver and chronic heart and lung dis- 
eases. The condition is known as cyanotic induration, on 
account of the characteristic color and firmness. The 
spleen is larger and bluish-red in color; the capsule is tense, 
and the pulp soft. As the condition persists, there is an 
increase in the connective tissue of the capsule and the tra- 
beculae. There may finally be an atrophy of the splenic 
pulp, with contraction of the fibrous tissue, so that the organ 
becomes smaller, firmer, and somewhat distorted. 

Hemorrhage is usually the result of traumatism, and 
occurs beneath the capsule. A common form is that which 
occurs in hemorrhagic injarction as a consequence of em- 
bolism. The conic area has its base toward the periphery 
and the apex toward the hilum. It rapidly breaks down, 
and if micro-organisms are present, an abscess may form. 
Otherwise the detritus is gradually absorbed and replaced 
by fibrous tissue which forms an irregular, contracted scar 
in which there is frequently more or less pigment. 

Embolism is quite common and causes either hemor- 
rhagic or anemic infarcts. The anemic is similar to the 
above, except that it is paler on account of containing less 
blood. 

Thrombosis of the splenic vein is generally secondary to 
a similar condition of the portal vein. 

Splenic tumor is the term apphed to the enlargement 
that occurs in infectious diseases. The organ is large, dark 
colored, red or reddish-black, and very soft; the capsule is 



THE DUCTLESS GLANDS 461 

stretched; the trabeculae and the Malpighian bodies are 
invisible on section, and the tissue is very friable and mushy. 
Microscopically the vessels are dilated and the pulp is com- 
posed of great numbers of lymphocytes and polymorpho- 
nuclear leukocytes. Many large mononuclear cells con- 
taining erythrocytes are present. Mitotic figures are fre- 
quently found in them. Small areas of focal necrosis are 
also frequently present. 

The enlargement of the spleen subsides as the disease 
declines, but it seldom gets quite as small as before the attack, 
on account of the fibrous overgrowth that occurs. 

Acute splenitis is usually of a suppurative character, due 
usually to hematogenous infection. Abscesses, either single 
or multiple, form. They may be absorbed or may rupture 
into some neighboring cavity, as the peritoneal, or into the 
stomach, intestine, lung, or pleura. 

Chronic splenitis is generally diffuse, and is characterized 
by a great hyperplasia of the connective tissue. 

The spleen is at first enlarged, but becomes smaller as the 
process continues. The capsule is stretched and much 
thickened, and may contain circumscribed areas that are 
almost cartilaginous in their density. The trabcculcT are 
also thickened. The organ is then quite firm, and may be 
dark in color on account of the presence of pigment. 

Tuberculosis of the spleen is rare as a primary affection, 
but is quite frequent as a secondary condition, and appears 
as a miliary infection. The tubercles are small grayish spots, 
not unhke the Malpighian corpuscles. They undergo a cen- 
tral caseation. 

Syphilis is very rare, but occurs in the form of gummata. 
They are generally multiple, and at first grayish, later becom- 
ing yellowish on account of degeneration in the central part 
of the node. There may also be a diffuse increase of the 
connective tissue. 

Atrophy of the spleen is very common in old age. The 
capsule is wrinkled and thickened, and the organ is pale, 
flabby, and pigmented, and there is an increase in the stroma. 
Circumscribed areas in the capsule of extreme thickness and 



462 A MANUAL or PATHOLOGY 

cartilaginous density may be present and be the cause of 
atrophy. 

Degenerations. — Amyloid disease affects the spleen more 
frequently than any other organ. It makes its appearance 
in the walls of the blood-vessels in the Malpighian bodies, 
and involves the adjacent tissue. The bodies become 
enlarged, pale, and translucent, resembhng boiled sago, 




Fig. 164. — Amyloid Degeneration of the Spleen (Sago Spleen). 
X 24 (Durck). 
I, An amyloid follicle, in which are seen only a few nuclei; the blood- 
vessels, in transverse section, have also undergone amyloid degeneration; 
2, compressed pulp-spaces; 3, trabecular. 

hence it is known as the sago spleen. Occasionally the degen- 
eration may be more diffuse, affecting the connective-tissue 
stroma. The cut surface is dry, translucent, firm, and friable, 
and is about the same color as dried beef. The edges also 
are rounded. The degenerated areas give a mahogany- 
brown color on the addition of iodin. 

Pigmentation of the spleen is found in chronic congestion. 



THE DUCTLESS GLANDS 463 

as in cirrhosis of the liver and in malaria. Hemolysis takes 
place, and the freed pigment is found in the walls of the blood- 
vessels and in the parenchyma cells. In malaria the pig- 
ment is melanin, in other conditions hemosiderin. Exter- 
nal pigments, as coal-dust, may lodge in the spleen. It 
gains entrance into a blood-vessel by erosion from pressure 
of an anthracotic lymph-node. 

Calcification is found occasionally in old infarcts, in a 
thickened capsule, and in degenerated areas of tuberculosis 
and syphilis. 

Leukemia. — The spleen becomes greatly enlarged, weigh- 
ing at times as much as 5 to lo kilograms. The capsule is 
much thickened. In the early stage the organ is enlarged 
and soft, but finally becomes firm and dense, on account of 
the hyperplasia of the lymphoid tissue. On section, the 
spleen is seen to be very much congested, and the Malpighian 
bodies appear quite prominent. 

There is anemia resulting from pressure of the capsule on 
the pulp; many of the cells degenerate, and both anemic 
and hemorrhagic infarcts may occur. On section, the cut 
surface is found to be very mottled. Reddish areas, small 
yellowish necrotic masses, whitish bodies of lymphoid tissue, 
and infarctions may all be present. Microscopically the 
Malpighian corpuscles are found much enlarged, and con- 
tain cells showing mitoses. The new cells may be larger 
than normal, and giant- cells arc occasionally seen. The 
pulp is congested and degenerated, containing pigment and 
large phagocytic cells in which arc found erythrocytes and 
detritus. 

Tuberculosis is not infrequently present at the same time 
as leukemia, and may modify the general appearances. 

Pseudoleukemia. — The gross appearances are practi- 
cally the same as in leukemia, but there are differences in 
the microscopic picture. "In the spleen and lymph-nodes 
there is hyperplasia of the lymphoid tissue, proliferation of 
endothehoid cells, formation of uninuclear and multinuclear 
giant-cells, thickening of the reticulum, and final overgrowth 
of connective tissue. Eosinophiles, though not specific, are 



464 A MANUAL OF PATHOLOGY 

frequently found in great abundance. There is also an 
increase in the eosinophihc leukocytes and myelocytes of 
the bone-marrow." 

Tumors. — Primary growths are rare. Secondary sar- 
coma and carcinoma are frequently found in generalized 
metastasis. 

Cysts are rare. Small ones may be due to degeneration 
of a follicle. Large ones are occasionally found. 

Parasites are also rare, but the Pentastomum denticula- 
tum, the cysticercus, and the Tcenia echinococcus have all 
been described, the last the most frequently. 

THE LYMPH-NODES 

Anemia. — The nodes are softer, shrunken, and drier than 
normal. 

Hyperemia is characterized by an increase in size of the 
nodes, which are reddish in color and very moist. The 
change is more marked in the capsular and cortical portions 
than in the center. It is generally the beginning stage of 
inflammation. 

Atrophy of the nodes occurs chiefly in old age. The 
lymphocytes in the medullary portion degenerate, fatty 
metamorphosis of the connective tissue occurs, and the nodes 
become smaller, hard, and dry. 

Hypertrophy is usually considered among the tumors as 
lymphadcnoma. 

Degenerations. — Amyloid occurs in cases of general amy- 
loid disease. The tissues first affected are the walls of the 
small blood-vessels and the connective tissue of the trabecu- 
lae; the endothehal cells are affected later. 

Hyaline changes are occasionally seen in the walls of the 
blood-vessels and trabeculae. 

Calcification of lymph-nodes is a not infrequent end result 
in necrotic lesions. There may be small scattered areas of 
calcareous matter or a diffuse infiltration of the node. 

Pigmentation may result from the presence of internal or 
external substances. Hemosiderin is the commonest blood- 
pigment. It may form as a result of local extravasation of 



THE DUCTLESS GLANDS 465 

blood, or it may be carried to the node by the blood from a 
hemorrhage in some adjacent tissue. The pigment-granules 
are found within the lymphocytes or in the cells of the stroma. 
The amount present may be very scanty, or so plentiful as to 
give a rusty color to the tissue. 

External pigments, as in pneumonokoniosis or in tattooing, 
may find their way into the lymph-nodes, being carried there 
by leukocytes and other phagocytic cells. As a rule, the 
substances acting as irritants bring about a connective-tissue 
hyperplasia. Occasionally softening may result instead. 
If septic material is conveyed to the nodes, suppuration 
occurs. 

Inflammation or lymphadenitis is secondary, as a rule, 
to the extension of inflammation from neighboring tissues. 
The infection is commonly of lymphogenic origin. The 
node becomes swollen, hyperemic, and tender. It may be 
dark red from hemorrhages. Microscopically the spaces 
are found filled with erythrocytes, leukocytes, and some 
fibrin. 

The process may be so severe as to bring about suppura- 
tion and abscess formation. Such a condition in the super- 
ficial nodes is termed a bubo. If deep-lying nodes are the 
seat of abscess formation, serious consequences may result 
from perforation into some internal cavity. 

If the inflammation subsides during the early stage, absorp- 
tion of the exudate takes place, the leukocytes pass into the 
circulation or break down, and the fibrin also softens. If 
there has been pus-formation, absorption may not take place. 
The pus causes hyperplasia of the neighboring connective- 
tissue cells, and they form a capsule. Such abscesses may 
calcify. At times the necrotic masses may be entirely 
absorbed and be replaced by a great overgrowth of connective 
tissue. 

Chronic lymphadenitis may follow numerous acute attacks 
or long- continued irritation, as in tuberculosis, syphihs, and 
other chronic infectious diseases. There is an increase in the 
connective tissue, with usually atrophy or necrosis of the 
lymphoid structures. 

30 



466 A MANUAL OF PATHOLOGY 

Tuberculosis of the lymph-nodes may be primary, but 
is much more frequently secondary to disease in a neighbor- 
ing structure. The specific organism is carried to the node 
by the lymph- channels. 

In tuberculosis of the cervical nodes the tubercle bacillus 
gains entrance through the tonsil without causing disease at 
that point. The same condition may occur in the mesenteric 
nodes without involvement of the intestinal mucous mem- 
brane. 

The tubercular nodes are enlarged, and at first hyperemic, 
although later they become paler. In the substance of the 
node numerous mihary tubercles may be seen, or the tissue 
may be represented by a broken-down caseous mass in the 
center. The caseation may continue until the node becomes 
a softened, semifluid mass. The process may involve neigh- 
boring structures, and finally rupture externally, with the 
formation of a discharging sinus. 

If the course is less acute, there may be very extensive 
connective-tissue hyperplasia around the disease focus, the 
progress being impeded in that way. Calcification may 
finally take place. 

This variety of tuberculosis is comparatively benign. It 
must be remembered, however, that although a node becomes 
encapsulated and even calcified, it is still infectious. Though 
the organisms may not be recognizable microscopically, yet 
injection of the material into animals will usually give rise 
to the disease. 

The microscopic appearances are the same as are found 
in tuberculosis in other pasts of the body. 

Syphilis. — In the secondary stages there is a lymphadenitis 
and associated with the primary lesion there may be some 
enlargement of the nodes. The inguinal nodes may become 
quite swollen, and at times suppurate. Such a condition is, 
however, probably due to there being a mixed infection. 

The nodes are hard, and there is no tendency to soften 
and suppurate. Microscopically there is seen a leukocytic 
infiltration, with thickening of the trabeculas and prolifera- 
tion of the endothelium of the lymph-spaces. The walls of 



THE DUCTLESS GLANDS 467 

the blood-vessels are thickened, and show round-cell infiltra- 
tion. 

In tertiary syphilis small gummata may form in the 
lymph-nodes, particularly in the lymph-sinuses. They are 
grayish, degenerated, and gummy, and are composed of 
leukocytes, lymphocytes, and other cells, all of which show 
fatty and hyaline degenerations. 

Leprosy, glanders, and actinomycosis are present at 
times in the nodes, and show characteristic lesions. 

Tumors.— Leukemia. — In the lymphatic form there is a 
general hyperplasia of the lymphatic tissues in the body. A 
few nodes or many may be involved, and metastatic deposits 
of lymphoid cells are found where normally none exist. 
Little change is evident; under the microscope, the enlarge- 
ment is seen to result mainly from an increase of the lymph- 
cells without much hyperplasia of the reticulum or vessels. 

The diagnosis has to be made by the changes present in 
the blood. 

Pseudoleukemia {Hodgkin's disease) is a condition some- 
what resembling an infectious disease, and is characterized 
by certain changes occurring quite generally in the lymphatic 
tissues. The appearances as described in the spleen {q. v.) 
are the same as occur in the lymph-nodes. The blood shows 
no definite changes. 

Lymphoma or lymphadenoma refers to all enlargements 
of the lymph-nodes irrespective of the cause. The nodes 
are described as being of two varieties, the hard and the soft. 

In the hard variety the nodes are enlarged and hard, the 
capsule thickened, and the trabeculae increased. There is 
a great increase in the connective tissue and some hyper- 
plasia of the lymph-cells. 

In the sojt the nodes, though enlarged, are softer and 
grayish. They do not suppurate. Microscopically the in- 
crease of the lymphoid tissue is the marked feature. 

The enlargement of the nodes is sometimes referred to as 
lymphosarcoma, particularly when metastatic deposits of 
lymph-tissue are found in various organs, as the liver, kidneys, 
and heart. 



468 A MANUAL OF PATHOLOGY 

Sarcoma may develop in a lymph-node, and, breaking 
through the capsule, involve adjacent tissues. Metastases 
occur in the internal organs without involving other lymph- 
nodes, and in that way is differentiated from lymphosarcoma. 
IMicroscopically the primary tumors may resemble each other 
so closely that they frequently cannot be told apart. Other 
forms than the round-cell, such as spindle-cell, occur. 

Carcinoma, secondary in origin, is a very common condi- 
tion of the lymph-nodes. It is found in those nodes that are 
nearest to the seat of the disease, and is due to the carrying 
of carcinomatous cells by the lymph-stream to 'the node. 

THE THYMUS GLAND 

Malformations. — The gland may be very small or com- 
pletely absent. Sometimes it is so much enlarged as to cover 
the pericardium and the great vessels. It generally begins 
to atrophy by about the second year, but traces may remain 
until puberty or later. 

Hyperemia with punctate hemorrhages is found in cases 
of death from asphyxia. 

Inflammation is very rare, and takes the form of small 
abscesses. It may occur from extension of inflammations 
from adjoining tissues. 

Tuberculosis occasionally occurs. 

Syphilis occurs in the form of gummata, particularly in 
the new-born with congenital syphilis. 

Tumors. — Lymphoma and lymphosarcoma may originate 
within the thymus or its remnants. 

THE BONE-MARROW 

The marrow is lymphoid tissue consisting of a connective- 
tissue reticulum in which are numerous capiUaries and ve- 
nous vessels. The marrow-cells are large and round, and 
contain clear nuclei of vesicular character. Besides these 
there are many eosinophilic cells, endothelioid cells, fat cells, 
nucleated and non-nucleated red blood- corpuscles, giant- 
cells, and cells containing erythrocytes and pigment. 



THE DUCTLESS GLANDS 469 

In early life the marrow of the long bones is reddish, but 
the color finally changes to yellow, on account of the increase 
of the fat. 

Anemia. — In pernicious anemia the fatty tissue disappears 
and the marrow returns to its early condition. The color, 
however, is a darker red than usual. The change begins at 
the epiphyses, and extends toward the center of the shaft. 

In leukemia the marrow is rather gray in color, and scat- 
tered throughout may be seen small pale areas which consist 
of leukocytes. These areas may be so numerous as to give 
an appearance of suppuration. The myelocytes in mye- 
logenous leukemia are supposed to be formed in the bone- 
marrow. 

In typhoid jevcr the marrow contains areas composed of 
many lymphoid cells, large phagocytes, and foci of necrosis. 
The lesions are similar to those found in the other lymphatic 
tissues in typhoid. 

Atrophy occurs in old age and marasmic conditions. The 
fat is absorbed, and the number of cells decreases. 

Hypertrophy is the term applied to the changes that take 
place in anemic conditions. 

Degenerations. — Fally infillraiion occurs normally up to 
about the sixteenth year. It may be developed excessively 
in cases of general obesity and in conditions of ill nutrition. 

Mucoid degeneration is sometimes seen. 

Fatty degeneration occurs in severe infections. 

Necrosis may be part of inflammatory conditions. 

Pigmentation occurs in the marrow in cases of malaria, or 
in conditions causing hemolysis. External pigments, as an- 
thracosis, may be deposited in the marrow by the blood. 

Inflammation or osteomyelitis occurs in the various 
severe infectious diseases, as ty[)hoid fever, smallpox, etc. 
The marrow becomes redder than normal, punctate hemor- 
rhages occur, focal necroses and cellular infiltration of the 
blood-vessel walls are present, and also granular degenera- 
tion of the cells. At times the marrow may be distinctly 
purulent. The specific diseases and tumors are dealt with 
in the chapter on Diseases of the Bones. 



CHAPTER XXVI 
DISEASES OF THE BRAIN 

THE DURA MATER 

Hyperemia may be active as a result of injuries or dis- 
ease of the skull. Passive hyperemia may follow thrombosis 
of the venous sinuses. Neither of the above can be well 
recognized postmortem, as by that time hypostasis has taken 
place and the blood has sought the lower levels. 

Thrombosis of the sinuses is frequently secondary to 
extension of inflammation from adjacent bony structures, as 
in mastoid and middle-ear disease. It also occurs in infec- 
tious diseases, and is usually located in the superior longitu- 
dinal sinus. Cerebral softening or abscess formation with 
pulmonary or cardiac embolism may follow thrombosis and 
cause death. 

Hemorrhage is commonly due to injury, and may take 
place on the internal or external surface of the dura. A 
comparatively large amount of blood may collect between 
the skull and the dura, — an internal cephalhematoma, — and 
give rise to serious compression symptoms. Small hemor- 
rhages, frequently multiple, may be found in the substance 
of the dura after death by suffocation. 

Inflammation of the Dura. — Acute pachymeningitis is 
the result of infection following injury or disease of the skull. 
It may be local or general, and is characterized by the pre- 
sence of pus. The dura is much thickened and swollen by 
round-cell infiltration, and is covered by a layer of purulent 
material. Hemorrhagic pachymeningitis is found in the old, 
the insane, and in alcoholics, usually in the area that is sup- 
plied by the middle meningeal artery. There is an escape 
of erythrocytes to a greater or less extent, at times so marked 

470 



DISEASES OF THE BRAIN 



471 



as to simulate a hemorrhage. The coloring-matter may be 
absorbed and leave a collection of serous fluid — a hygroma. 

Chronic internal pachymeningitis is of obscure etiology, 
probably hematogenic, and is usually accompanied by dis- 
ease of the pia and arachnoid. It is characterized by the 
deposition of numerous layers of fibrinous exudation upon 
the internal surface of the dura. These gradually undergo 
fibrous replacement, with frequently the formation of many 
new capillaries. The dura becomes more adherent to the 
bone, and calcareous infiltration is sometimes encountered. 

Tuberculosis of the dura usually follows tubercular dis- 




P'lG. 165. — Section of a Psammoma of the Dura Mater. 

(Zicgler). 



X 200 



ease of the bones of the skull or of the pia-arachnoid. It 
may be present as miliary tubercles or as large caseous 
masses. 

Syphilis may give rise to a pachymeningitis fibrosa, 
causing a dense thickening of the dura. It may also be pre- 
sent as gummata, which may have originated either within 
the dura or within the bones of the skull, and have secondarily 
invaded the membrane. 

Tumors. — The most common is the sarcoma, which may 
be either spindle or round-celled, and quite often alveolar. 



472 A MANUAL OF PATHOLOGY 

These growths extend from the inner surface of the dura 
toward the brain. They may be flat or more elevated, and 
vary greatly in size. If they form on the outer surface of the 
dura, they may cause absorption of the bone and perforation. 
If the blood-supply is very rich, these growths are called 
angiosarcoma. Endothelioma may develop upon the inner 
surface of the membrane. Other forms of primary tumors 
are rare, psammoma, lipoma, and fibroma seldom occurring. 

Secondary tumors may follow malignant disease of neigh- 
boring structures — may be sarcoma, glioma, or carcinoma. 

Parasites are rare; the echinococcus and the Cysticercus 
celliiloso' have been described. 

THE PIA AND ARACHNOID 

Circulatory Disturbances. — Anemia occurs only as a 
part of a general condition. 

Active hyperemia is frequent, being the earliest stage of 
meningitis. It is also found in death from alcohol, in the 
infectious fevers, as typhoid and cholera, in certain poison- 
ings, and in delirium of various kinds. The pia is red, and 
the smaller vessels are injected. The subarachnoid fluid 
may be increased in amount and cloudy. 

Passive hyperemia is rather difficult to recognize post- 
mortem, on account of the hypostasis that occurs. The 
large veins arc distended and tortuous, the arachnoid is cloudy, 
and there may be more fluid than normal. This condition 
occurs in chronic heart and lung diseases and in venous 
obstructions. 

Hemorrhage into the subarachnoid space from the vessels 
of the pia may occur in anthrax and in such diseases as scurvy, 
hemophilia, and in severe infections. The hemorrhages 
may be numerous and small, or there may be a single large 
collection of blood between the pia and arachnoid. This 
latter form is generally the result of some severe injury, or 
due to the rupture of an aneurysm. The blood, instead of 
being upon the surface of the brain, may gain entrance into 
the ventricles. 

Small collections of blood may be absorbed and leave noth- 



DISEASES OF THE BRAIN 473 

ing but a small, and slightly yellowish area. If the amount 
has been large, the pigment may be absorbed and leave a 
clear, serous fluid. 

Edema may be present as an increase of the cerebrospinal 
fluid. A large collection of fluid between the pia and arach- 
noid is known as an external hydrocephalus. In senile 
atrophy of the brain there is an accumulation of fluid to fill 
out the loss of substance — hydrops ex vacuo. The edema 
may be gelatinous in character in paresis and insanity. 

Inflammations. — Leptomeningitis or inflammation of 
the arachnoid and pia may be acute or chronic, and the acute 
may be classified according to the exudate. 

Acute leptomeningitis is an infectious condition due to 
various organisms. The pneumococcus is the one found in 
the greatest number of cases, but many varieties have been 
described. In the epidemic meningitis the Diplococcus 
intracellular is me7ii?igitidis of Weichselbaum has been rec- 
ognized as the cause. The infecting agent gains entrance 
either as a result of wounds, by way of the lymphatics, or by 
direct extension. 

Serous leptomeningitis consists of round-cell infiltration 
of the membranes, with hyperemia and the exudation into 
the subarachnoid space and ventricles of a serous fluid. 
This may be slightly cloudy from leukocytes that are some- 
times present. This form occurs in children in the course 
of infectious diseases, as scarlet fever and measles; and in 
adults after sunstroke. It is probably the beginning stage 
of an infectious inflammation in which the death of the patient 
has followed before further lesions have had time to develop. 

Fibrino purulent leptomeningitis is probably a later stage 
of the preceding. In the subarachnoid space there is a col- 
lection of pus and fibrin. This may increase until the sulci 
are marked out as yellowish bands, and eventually the sur- 
face of the brain may be covered by this purulent exudate. 
The process may be confined to local areas, or involve both 
hemispheres. If at the vertex, it is known as cortical men- 
ingitis; at the base, as basilar meningitis. 

The pus may gain entrance into the ventricles, or it may 



474 A MANUAL OF PATHOLOGY 

follow along the blood-vessels, particularly the middle men- 
ingeal, and involve the cortical substance with degenerative 
changes in both cells and fibers. Small hemorrhages may be 
present and discolor the exudate. The termination is usually 
fatal, but absorption and recovery may take place. There 
are, however, permanent structural changes, as a rule. 

Epidemic cerebrospinal meningitis resembles the above 
form, except that it has a specific organism, the Diplococcus 
inlracellularis, as its cause. It generally starts upon the con- 
vexity of the frontal lobes, and extends backward and down- 
ward, involving the basal membranes and those of the cord 
later on. Death may, however, take place so suddenly that 
distinct changes may not be noticeable. 

The spinal changes may be more marked than those of the 
brain, the cord being covered by a thick yellowish layer of pus 
and fibrin. Occasionally the central canal may contain pus. 

Chronic leptomeningitis is an inflammation of the pia, 
usually secondary to diseases of the brain or dura. There 
is a hyperplasia of connective tissue and round-cell infiltra- 
tion. The thickening may be so great as to cause compres- 
sion of the brain-substance or oljliteration of venous channels. 
Large or small areas may be involved, and adhesions between 
the pia and the dura or the brain may form. 

Tuberculous meningitis is more common in children 
than in adults, and is generally found upon the basilar sur- 
face. This location is so frequent that the term basilar 
meningitis refers to a tubercular process. This disease may 
be primary, but is, as a rule, secondary to tuberculosis 
elsewhere, particularly of the lung. 

Upon the pia over the pons, about the optic chiasm, and 
along the Sylvian artery are found the miliary tubercles, the 
characteristic lesions of the process. They may also be 
noticed in the choroid plexus and the ependyma as a result 
of extension. The tubercles vary in color from gray to yel- 
low, according to their age. 

There is generally some exudate, either serofibrinous or 
purulent, especially if there has been a mixed infection by 
the pneumococcus. This may be so thick as to obscure the 
tubercles. 



DISEASES OF THE BRAIN 475 

Most of the tubercles are found around blood-vessels, 
and consist at first of a cellular infiltration, with some thick- 
ening of the vessel-wall. Giant-cells are not as common 
as in tuberculosis elsewhere. As the disease persists, degen- 
eration and caseation take place. 

If the infection has been primary, there may be a single 
large tubercular area — a tyroma. Such a mass may be soft 
from liquefaction necrosis, or fairly firm; occasionally it 
may be the seat of calcareous infiltration. 

Syphilis is found in the pi a, usually in the form of gum- 
mata which may extend and involve the brain or the dura. 
This form is found as circumscribed, flattened thickenings 
that generally show necrotic processes. 

Another form is characterized by a perivascular round- 
cell infiltration which may become diffuse. This portion of 
the pia may become quite thickened and grayish-red in color. 
Caseation takes place around the edge of the node, and the 
destroyed portion is gradually replaced by dense cicatricial 
tissue. 

It may occur as a widespread leptomeningitis. 

Tumors. — The Pacchionian bodies are numerous small, 
rounded, projecting structures found along the longitudinal 
sinus. They consist of fibrous tissue that originates within 
the arachnoid, but as they grow they force their way at times 
through the dura and cause a firm union of the membranes. 
There is also very frequently more or less atrophy of the skull, 
causing depressions into which these bodies fit. In places 
the bone may be greatly reduced in thickness. These bodies 
are found in nearly every adult body, and appear to be of 
no significance. 

Endothelioma and pcrithcUoma are found in the membranes, 
having originated from the cells of either the lymphatics 
or the blood-vessels. They may become sufficiently large 
to cause pressure symptoms, but are usually small. Sarco- 
ma may occur in the form of angiosarcoma or cylindroma. 
Fibroma, lipoma, and myxoma are occasionally seen. Cho- 
lesteatomata are sometimes found in the pia, generally at the 
base of the brain. Teratomata are rarely encountered. 



476 A MANUAL OF PATHOLOGY 

Secondary growths arc not infrequent, either by direct exten- 
sion or by metastasis. 

Cysts are rare. 

Parasites are unusual, but the echinococcus and the 
Cystico'cus cclliilosce have been observed. 

THE BRAIN 

Malformations of the brain may be associated with 
deformities of the skull, or may occur independently. Acra- 
nia is an absence of the skull, but usually with preservation 
of the membranes and a small mass of nerve tissue. Hcmi- 
crania is an undeveloped condition of the skull and l)rain on 
one side. Ancnccphaly refers to a condition in which there 
is almost complete lack of brain-substance; it is usually 
associated with acrania. Ccphalocdc is a hernia of the brain- 
substance through fissues or openings. 

Hypoplasia or microcephaly is a condition in which the 
brain is unusually small, but properly ])roportioned. It is 
frequently associated with some degree of external hydro- 
cephalus. Macrocephaly, or increase in size of the brain, 
is generally due to a hyperplasia of the neurogliar tissue. 
Porencephaly refers to the presence of definite holes or depres- 
sions in the brain-substance. It may be the result of soft- 
ening following infarction. 

Hydrocephalus is a collection of fluid either within the 
venlricles of the brain or in the subarachnoid space. It 
may be external to the arachnoid, or internal^ and may be 
congenital or acquired. 

External hydrocephalus is frequently ex vacuo to supply by 
an exudate a loss of cerebral tissue. 

Internal hydrocephalus is a collection of lluid within the 
third and lateral ventricles of the brain. The amount of 
fluid may \'ary greatly. The ])rocess generally begins before 
birth, and may cause serious obstruction to labor. The 
condition is generally bilateral. After birth, if the accumu- 
lation of Huid persists, there is a very typical deformity of 
the skull. The presence of the fluid within prevents the 
bones of the brain from uniting. The sutures are pushed 



DISEASES OF THE BRAIN 



477 



far apart, giving a peculiar bulging to the forehead. The 
head becomes quite large and round, the face small, and the 
eyes may project. The cerebral tissue, on account of the 
pressure, shows a marked flattening of the convolutions. 

The dura and pia may be thin or thick, and the choroid 
plexuses of the ventricles may 
be hypertrophied or cystic. 

The collection of fluid will 
or v^ill not interfere with the 
mentahty of the individual ac- 
cording to the amount that is 
present. In very marked cases 
it is incompatible with hfe, but, 
if less severe, the individual may 
hve, although more or less of an 
imbecile. 

The cause of this condition 
is not known, but by some it 
is thought to be due to alcohol- 
ism in the parents; to inflam- 
matory conditions of epcndyma 
and choroid plexus; to closure 
of the transverse fissure, causing 
obstruction to the escape of 
fluid from the ventricles; and 
to changes in the pressure within 
the cerebral veins. 

Acute acquired hydrocephalus 
is generally found as a result of 
basilar meningitis. The brain 
is pale, soft, and the convolu- 
tions flattened; the contained 
fluid is frequently gelatinous. 

The epcndyma and choroid plexuses are injected, and if 
the process was tubercular, tubercles will be found. The 
substance of the brain will show under the microscope the 
presence of smaU areas of suppuration. 

Chronic acquired hydrocephalus generally occurs late in the 




Fig. 1 66. —Congenital Inter- 
nal Hydrocephalus, with 
Marked Atrophy of the 
White Substance (from 
Bollinger). 



478 A MANUAL OF PATHOLOGY 

course of epidemic meningitis or as a consequence of a 
chronic granular ependymitis. 

Epcndymitis may be cither acute or chronic. The acute 
form is associated with acute meningitis, and in it there is a 
thickening and leukocytic infiltration of the ependyma and 
pia. In chronic ependymitis the surface is granular, the 
ependyma is thrown into folds and becomes much thicker on 
account of a hy])erplasia of the contained neurogliar fibers. 

Circulatory Disturbances. — Anemia of the brain is 
characterized by a pallor of the cortex and white substance 
as a result of the diminished amount of blood. It is due to 
general anemia, severe hemorrhage, disease of the blood- 
vessels, particularly atheroma, increased intercranial pres- 
sure, or to spasmodic contraction of the blood-vessels. 

Acute Hyperemia. — The amount of blood in the brain is 
increased during its activity. Pathologically, it is found 
in beginning infiammations, in infectious diseases, acute 
dehrium, sunstroke, etc. The blood-vessels in the pia are 
injected, the cortex is darker than normal, and minute hem- 
orrhages may be present. 

Passive hyperemia occurs in any of the conditions that 
prevent the blood escaping from the cerebral veins, as heart 
disease or local growths. The veins of the membranes are 
much distended, and the cortex and medulla are of a bluish 
tinge. 

Edema of the brain is generally secondary to conditions 
causing passive congestion. There may be a slight edema 
that is soon taken up by the lym])hatics. The fluid is most 
marked in the subarachnoid and ventricular spaces. The 
membranes are elevated, and the convolutions are flattened. 
The edematous fluid contains more albumin and is more 
cloudy than the normal. Indications of inflammation are 
usually present. This condition may be a terminal pheno- 
menon. It is found in renal disease and in alcoholism. In 
the latter there is frequently a great excess of the fluid. 
Microscopically, there may be some proliferation of the endo- 
thelium, and around the blood-vessels there is some round- 
cell infiltration. Local edema is sometimes found in the 



DISEASES OF THE BRAIN 479 

neighborhood of areas of softening. In acute hydrocephalus 
the internal capsules may be involved and transient hemi- 
plegia follow. 

Hemorrhage occurs in two forms, minute {punctate) or 
massive. 

Punctate hcmorrliages are small collections of blood formed 
by diapcdesis of the erythrocytes or by rupture of a small 
vessel. They are generally found in the cortex, and occur 
in the course of inflammation of the brain, in various infec- 
tious diseases, and in toxic conditions, particularly lead- 
poisoning. They seldom cause any secondary disturbances. 

Massive hemorrhages, unless traumatic, are commonly 
found to affect the branches of the middle cerebral artery. 
In these cases there has generally been a pre-existing disease 
of the vessel, the rupture usually taking place in a small 
aneurysm. It is commonly known as apoplexy. The inter- 
nal capsule is almost always involved. The pons is quite 
frequently the seat of hemorrhage, and occasionally the 
cerebellum, but very rarely the medulla. 

The size of the involved area depends upon the amount 
of blood extravasated and upon the density of the tissue. 
It is more diffused in the white than in the gray matter. The 
effects of the hemorrhage may be primary or secondary. 

Primary effects are tearing and compression of the brain- 
substance. If the patient does not immediately die, soft- 
ening occurs. As a result of the staining by the retained 
hemoglobin the area is known as red softening. Shortly 
after the blood escapes it undergoes coagulation, forming 
a cerebral hematoma. This acts as a foreign body and sets 
up an inflammatory reaction, with more or less hyperplasia 
of the surrounding neuroglia. The fluid portion finally 
becomes absorbed, the corpuscles broken down, and the 
pigment liberated, which stains the walls of the cavity. Oc- 
casionally a cyst filled with a clear fluid may form. If all 
fluids are absorbed, the walls of the cavity may come in con- 
tact and a scar result. 

Other primary effects are distant ones in the form of par- 
alvsis, both motor and scnsorv, and s^cnerallv on the side of 



480 A MANUAL OF PATHOLOGY 

the body opposite to the seat of the hemorrhage. Although 
there may be a considerable return of the lost faculties, yet 
in a majority of cases permanent damage is done. This is 
due to the secondary effects — the secondary degenerations. 
These are systemic, and follow the direction of the nerve 
impulses. The commonest degeneration is one of the pyra- 
midal tracts. The optic tract and fibers from the temporo- 
sphenoidal area may also be involved. In the brain there is 
finalh' loss of nerve-cells, without destruction of the ncurog- 
liar fibers. 

As a result of traumatism, hemorrhages may take place in 
any part of the brain, with or without fracture of the skull. 
The hemorrhage may be found on the side of the head oppo- 
site to that where the ])low was received. 

Thrombosis and Embolism. — Thrombosis is most com- 
mon as a result of embolism or of endarteritis. It may be 
found anywhere, but is probably more frequent in the basi- 
lar artery. From obstruction to the nutrition cncephalo- 
malacia, or softening of the brain, ensues. 

Embolism commonly results from a breaking off of a part 
of a verrucosity or of a leaflet of one of the heart valves, especi- 
ally the aortic. The greater number of the emboli pass along 
and finally lodge in the artery of the Sylvian fissure. If the 
embolus is so large as to remain at the beginning of the artery, 
there will be a large degenerated area. The corpus striatum, 
a large part of the internal capsule, and the anterior part of 
the optic thalamus will be involved. As different branches 
are obstructed, the areas of degeneration will vary. If the 
emboli are so small as to enter the posterior perforated space, 
the optic thalamus only will show small areas of degeneration. 

Degenerations. — Enccphalomalacia, or local softening of 
the brain, is found in ischemia, as a result of arteriosclerosis 
of the smaller vessels, in thrombosis and embolism, and in 
meningitis and encephalitis. The brain-substance breaks 
down and undergoes colliquation necrosis. The areas of 
softening are usually referred to by the color that they present. 
They are, however, not different processes, but merely 
different stages of the same condition. 



DISEASES OF THE BRAIN 481 

White sojtening is a coUiquation necrosis occurring when 
the blood-supply has been completely and permanently cut 
off. If this area is incised, the contents will escape, leaving 
an irregular cavity with ragged borders, and in it will be 
found some nerve-fibers and neuroglia. The escaped con- 
tents are composed of degenerated nerve-structures, with fat- 
droplets, granule-cells, and leukocytes. 

Yellow sojtening may be due to an increased fatty degener- 
ation occurring in white softening or a late stage of red 
softening. 

Red sojtening is a breaking-down of nerve tissue accom- 
panied by the extravasation of blood. It may be due to a 
hemorrhagic infarction or to diapedesis. The contents of 
the involved area are not generally as fluid as in the other 
forms of softening. 

The areas of softening may vary greatly in size and in the 
time of their formation. The same process, however, goes 
on, the myehn sheaths degenerate, the axis-cylinders may dis- 
appear, compound granule-cells appear, and finally the ncu- 
rogliar fibers may soften. The broken-down tissue may be 
slowly absorbed, leaving a cyst with smooth, well-defined 
walls, and clear contents. The cysts may become encapsu- 
lated, or through absorption scar tissue form. 

Encephalitis, or inflammation of the brain-substance, is 
peculiar on account of the tissue that is involved. It differs 
from inflammation elsewhere in that conditions of degener- 
ation or softening are associated. 

Encephahtis may be acute or chronic, diffuse or circum- 
scribed. The causes of the condition arc many. It may 
result from injury ivithout injection; in this form there is a 
hemorrhagic extravasation, followed rapidly by necrosis. 
xA-round the necrotic tissue is a hyperemic zone in which there 
is some transmigration of leukocytes, and slight proliferation 
of the connective tissue of the sheaths surrounding the vessels. 
Injury with injection generally affects the membranes pri- 
marily, but soon involves the brain-substance. There is a 
marked leukocytic infiltration along the blood-vessels, and 
the brain-substance undergoes degenerative processes. In- 
31 



482 A MANUAL OF PATHOLOGY 

flammation of the brain may also be secondary to infectious 
disease elsewhere in the body. In hematogenic jocal enceph- 
alitis specific micro-organisms are brought to the brain by 
the blood. Numerous areas are found in which the blood- 
vessels are distended and interstitial hemorrhages are present. 
The lymphatics contain many leukocytes, and the nerve- 
tissues rapidly degenerate. If the patient survives long 
enough, suppurative encephalitis may ensue. This form is 
generally due to infection by the pneumococcus, streptococcus, 
or staphylococcus, and true abscesses, either single or multiple, 
are formed. If the extension has been by the blood, they will 
be multiple; if by direct continuity, as from middle-ear 
disease, they will be single. The size may vary greatly — 
they are generally about as large as a walnut. They are 
most frequent in the cerebrum, but may be found in the cere- 
bellum and rarely in the pons and medulla. When the acute 
processes subside, a proliferation of the surrounding neurog- 
liar tissue may occur and encapsulate the abscess. Toxic 
encephalitis is caused by the presence, in the circulating 
blood, of certain substances that act upon the nerve-cells and 
cause various changes that can be recognized by the employ- 
ment of special methods of study. These changes are found 
in the cells of both the brain and spinal cord in diphtheria, 
tetanus, lead-poisoning, and hydrophobia, also to some 
extent in alcoholism. Chronic encephalitis or sclerosis 
occurs in all cases of injury to the brain in which- recovery 
occurs. There is a chronic hyperplasia of the neuroglia, 
which may be local or diffuse. In multiple localized sclero- 
sis there are numerous scattered foci of degeneration, asso- 
ciated with hyperplasia of the neuroglia. They are sharply 
defined, slightly dense to the touch, and grayish or pinkish in 
color. Difjuse sclerosis is characterized by widespread 
areas of neurogliar hyperplasia. It is more common in 
children, and does not seem to be due to toxic or inflamma- 
tory conditions. It may be sharply circumscribed and 
resemble glioma. At first the brain may appear hyper- 
trophied, but later, as atrophy of the nerves occurs, it becomes 
smaller. Certain lobes or convolutions may be involved, 



DISEASES OF THE BRAIN 483 

and there is always considerable degeneration of the nervous 
structures. 

Tuberculosis of the brain may be primary or be secondary 
to tuberculosis of the meninges. When secondary, there are 
generally many small tubercles along the perivascular tissues, 
particularly along the small vessels of the anterior and poste- 
rior perforated spaces. Primary tuberculosis is hemato- 
genic, and occurs as single lesions. It is more common in 
children. The tubercle gradually becomes larger, and case- 
ous degeneration occurs, is rather dense, yellowish in color, 
and dry, and sometimes undergoes calcification or again 
contains a yellowish pmailent-hke matter. The growth 
increases in size by the formation and aggregation of new 
tubercles at the periphery of the original focus. These large 
areas are called tyromata. 

Syphilis of the brain generally appears as a gumma that 
has originated within the pia and extended to the brain. 
The gumma is at first grayish or reddish-gray, but very soon 
undergoes a secondary necrosis and caseation. Recovery 
takes place with the formation of a dense cicatrix. Syphihtic 
endarteritis is sometimes found and gives rise to secondary 
degenerations with softening. 

Tumors of the Brain. — The most frequent form of those 
found is the glioma. It is commonly found in the cerebrum, 
the cerebellum, the pons, and medulla. It is thought to 
never originate from the pia. The glioma appears as a dilTuse, 
poorly defined area, pinkish or reddish in color from the 
numerous blood-vessels that are present. The tumor may 
be composed purely of neurogliar tissue, without any nerve- 
cells or fibers present. Occasionally ganglionic cells, isolated 
or in groups, are found embedded in the neoplasm; such 
tumors are known as ganglioinata or neurogliomata. Micro- 
scopically ghomata are made up of cells from which numerous 
filaments project and which compose the groundworks of the 
tumor. 

Some gliomata are considered as sarcoma, but as the 
tumors arise from different embryonal layers, such a com- 
bination could hardly occur. The sarcoma differs clinically 



484 A MANUAL OF PATHOLOGY 

from the ordinary glioma in being of a more rapid growth 
and giving metastases. 

Sarcoma is fairly frequent, and commonly arises from the 
pia or from the connective tissue around the blood-vessels. 
It is generally rather circumscribed, and may be encapsu- 
lated. The commonest variety is the small round-cell, but 
spindle-cell and giant-cell forms occur. Angiosarcoma is 
not infrequent, and the perithelioma or myxangiosarcoma 
tuhulare is fairly common, Psammosarcoma, in which infil- 
tration of hme-salts takes place, is occasionally encountered. 
It is generally small and gritty. Endothelioma is found in the 
pia and sometimes in the choroid plexuses. 

Other forms of primary tumors are rare. As secondary 
growths, sarcoma and carcinoma are fairly frequent. 

Parasites are rare; the echinococcus and the cyslicercus 
celltdoscE have been found. 

THE PITUITARY BODY 

Hypertrophy is uncommon, but it occurs in cretinism, 
myxedema, and acromegaly. If the thyroid gland is removed 
it is thought that the pituitary body sometimes enlarges. 
The acini may contain a large amount of colloid material. 

Hyperemia may occur, and in cases of passive congestion 
there may be considerable edema. Hemorrhage may take 
place just before death, and erythrocytes will be found in the 
connective tissue. 

Inflammation is rarely primary, is usually secondary, as 
a result of extension, and suppuration may occur. The dura 
covering the gland may become much thickened, and as a 
result the pituitary body atrophies or undergoes a fibrous 
change. 

Tuberculosis in the form of miliary foci and syphilis in 
the form of gummata have been observed. 

Tumors. — Sarcomata, round-cell or spindle-cell, are some- 
times found. They develop apparently from the capsule 
of the gland and destroy the substance. They seldom infil- 
trate the surrounding tissue and do not give metastases. 

Adenoma causes a general enlargement and is the growth 



DISEASES OF THE BRAIN 485 

most commonly found associated with akromegaly. It con- 
sists of long, tortuous tubes, and causes atrophy of the poste- 
rior or nervous lobe. 

Teratoid growths have been described. 

Cysts are generally the result of retention of the colloid 
material. The epithelial cells disappear and the follicles 
distend. The cysts may grow to the size of a hen's egg. 



CHAPTER XXVn 

DISEASES OF THE SPINAL CORD 

Circulatory Disturbances. — Anemia of the cord may 
be due to pressure from neoplasms or to obstruction of small 
blood-vessels by disease or thrombosis. Embolism is fol- 
lowed by necrosis. In pernicious anemia degenerative 
changes in the posterior columns of the cord may occur. 

Hyperemia is present in all inflammations of the meninges 
or cord. Passive hyperemia is present in chronic heart and 
lung disease. Antemortem congestion is difficult to differ- 
entiate, as there is nearly always hypostasis of the blood into 
the spinal vessels. 

Hemorrhage into the cord is less common than in the brain. 
It may be punctate or massive. The punctate form occurs 
in death from convulsions, as in tetanus, after injuries, in 
degenerated areas, about tumors, after extreme congestion, 
and in other conditions. Massive hemorrhages are seldom 
larger than a small marble. They may find a way along the 
longitudinal fibers or occasionally rupture into the central 
canal. 

The changes that take place if the individual lives are 
similar to those occurring in the brain under like conditions. 

Myelitis, although strictly signifying an inflammation of 
the spinal substance, is used to indicate any form of degen- 
eration present in the cord. It may be primary or secondary. 
The primary form occurs at the seat of the injury, and is 
frequently a circumscribed condition. Secondary degeneration 
depends upon primary changes elsewhere, and is due to the 
destruction of nerve-cells or axis-cyhnders. It is generally 
considerably more extensive than a primary degeneration. 
The degenerated areas may be white, red, or yellow, accord- 

486 



DISEASES OF THE SPINAL CORD 487 

ing to the amount of blood present and the stage of the soft- 
ening. In the early stages the involved tissue is swollen 
and pinkish, and minute hemorrhages may be present. 
The tissue is at first softened, but finally becomes firmer as 
fibrous changes occur. Microscopically the myehn is found 
to be destroyed, J)reaking down into droplets that stain with 
osmic acid. The axis-cylinders swell up and degenerate, the 
nerve-cells show enlargement and finally disappearance of 
their nuclei. The tissues generally become disorganized 
and give rise to u^hite softening, there being no change in 
color. If the damage to the cord has been such as to cause 
extravasation of blood into the involved area, it will be 
known as red sojtening. As the blood is destroyed the pig- 
ment is set free, with the formation of areas of yellow sojten- 
ing. 

In purulent myelitis there will be found a round-cell infil- 
tration in the perivascular spaces, pus in the pia mater, and 
degeneration of the neighboring nerve-tissues. The gan- 
glion-cells, though very resistant, sooner or later show degen- 
erations. 

When the acute processes subside, there is some absorp- 
tion of the broken-down tissues and a hyperplasia of the 
neuroglia and connective tissue, constituting the early stage 
of sclerosis. The newly formed tissue is grayish in color, 
firm, dense, and dry. There is probably little, if any, attempt 
toward the regeneration of the nerve-fibcrs. 

Myelitis may be traumatic, infectious, toxic, or nutri- 
tional. 

Traumatic myelitis may result rapidly, but it is usually 
slow, as a result of compression of the cord by tumors or 
collections of fluid in the spinal canal. The degeneration 
generally extends entirely across the cord, lacing known as 
transverse myelitis. There are usually three stages, that of 
red softening, of yellow softening, and of gray degeneration, 
and connective-tissue hyperplasia. 

Injections myelitis may be transverse or disseminated, 
particularly the latter. Micro-organisms arc generally pres- 
ent in the lesions. 



488 



A MANUAL OF PATHOLOGY 



Varieties of Myelitis. — When the spinal membranes are 
inflamed, the condition is known as spinal meningitis; if the 
membranes and cord are both affected, meningomyelitis. 
Inflammation of the cord alone is known as myelitis; dis- 
ease of the white substance is leukomyelitis; if the gray 
matter, poliomyelitis. 

Myelitis is referred to as central when arising from dis- 
ease of the central canal; difjuse if it involves the entire 
cord ; transverse when a small section is entirely affected ; dis- 
seminated when there are numerous small areas more or less 
widely separated. 




^r^^^^^^^^^^;^^^"^^^ 











^ 



// 



f^ 



.^^' 



Fig. 167. — Hydromyelia (Partly Diagrammatic) (Stengel). 



It may be simple^ hemorrhagic^ or purulent^ or, according 
to development, acute or chronic. 

Hydromyelia is a condition in which the central canal 
of the spinal cord is dilated by an increased amount of 
cerebrospinal fluid. The dilatation may be irregular, usually 
being more marked in the lumbar cord. The canal may be 
round, slit-like, or triangular, and is commonly lined by epen- 
dymal cells, a condition that does not exist normally. Some- 
times the canal may be double or even triple, this being more 
frequent in the lumbar region. Hematomyelia refers to the 



DISEASES OF THE SPINAL CORD 489 

presence of blood in the central canal; pyomyelia, when 
pus is present. 

Syringomyelia is characterized by a central dilatation of 
the spinal canal resulting from the proliferation of the glia 
about the central canal and subsequent degeneration of the 
newly found tissue. 

The appearance is somewhat similar to that in hydro- 
myelia, but the canal is not lined by ependymal cells. 

The etiology of the condition is unknown. There is an 
extensive proliferation of gliar tissue around the central 
canal, probably beginning in the cervical portion, but extend- 
ing down the cord. This tissue rapidly degenerates and 
liquefies. The cavity is generally posterior to the center of 
the cord, and may be so large as to leave merely a thin layer 
of nerve tissue surrounding it. The canal in the early 
stages is filled with a brownish, gelatinous mass, which even- 
tually undergoes liquefaction, leaving the canal filled with 
clear fluid. 

The extent of the secondary degeneration in the spinal 
cord and in the anterior and posterior nerve-roots will depend 
upon the size of the lesion and the amount of pressure exerted. 
Entire columns of the cord and anterior and posterior nerve- 
roots may be destroyed in severe cases. 

Tuberculosis of the cord commonly involves the meninges, 
and secondarily extends into the nervous tissues; it is a 
meningomyclitis . Tubercles arc present in varying numbers, 
and soon cause thickenings and necrosis. Disseminated 
tubercles may be seen in both the white and the gray matter, 
but arc usually microscopic. Primary tuberculosis may 
occur in the form of a single circumscribed caseous mass. 

Syphilis of the cord usually appears as a thickening of the 
membranes, especially of the dura. Involvement of the i^ia 
and arachnoid is uncommon. There is found a marked 
endarteritis, and the formation of thrombi is quite frequent. 
Areas of cheesy degeneration arc due to the breaking-down 
of the diseased tissue. 

Tumors of the Cord. — The most common form is the 
glioma, as occurring in syringomyelia. It infiltrates the 



490 A MANUAL OF PATHOLOGY 

nerve tissue along the posterior portion of the cord. It 
seldom occurs as a circumscribed growth. Sarcoma, cylin- 
droma, and fibroma are very rare, but have been observed. 

Tumors oj the spinal meninges are more common. Prac- 
tically all varieties have been found. 

Cysts are extremely rare, but both the echinococcus and 
the cysticcrcus have been reported. 

Spinal Meningitis. — Pachymeningitis, or acute inflam- 
mation of the spinal dura mater, is commonly due to neigh- 
boring inflammations or to traumatism. In external pachy- 
meningitis there is an exudate, cellular or fibrinous, upon the 
external surface. Abscesses may form and destroy by pres- 
sure the neighboring cord. Internal pachymeningitis is 
generally secondary to tubercular or syphilitic disease of 
the pi a and the bones. There is a marked fibrous exudate, 
with adhesions between the dura and the underlying mem- 
branes. Hemorrhagic pachymeningitis is internal, and is 
similar to the process occurring in the brain. It is charac- 
terized by a reddish layer of granulations in which many of 
the capillaries have ruptured. 

Chronic hypertrophic cervical pachymeningitis is a local- 
ized thickening of the dura mater in the cervical region. 
The pia and the arachnoid are also involved. Compression 
of the cord and secondary degenerations may ensue. 

Leptomeningitis, or acute inflammation of the spinal pia 
and arachnoid, is generally secondary to cerebral meningitis, 
especially in the epidemic cerebrospinal form. It may be 
due to local injury or diseases of the bone. There is an 
exudation, serous, fibrinous, or purulent, upon the inner sur- 
face of the dura and the subarachnoid space. The inflam- 
mation may be local or involve the greater length of the cord. 
The tissue of the cord is commonly affected, and extensive 
round-cell infiltration occurs in the anterior commissure and 
in the perivascular connective tissue. 

SPECIAL DISEASES OF THE SPINAL CORD 

Disseminated or multiple sclerosis occurs in both the 
brain and the spinal cord, and is characterized in the early 



DISEASES OF THE SPINAL CORD 



491 



stage by the presence of many softened areas. These vary 
in size, are grayish in color, are more frequently found in the 
white matter than in the gray. There is a degeneration of 
the myelin and of the cells, but the axis-cylinders remain 
uninvolved for a long time. Hyaline degeneration of the 
blood-vessels is commonly present. As the disease pro- 
gresses, the softened areas are gradually replaced by a hyper- 
plasia of the gha tissue. There is also atrophy of the nerve- 
cells and of some of the axis-cvlinders. 




Fig. 168. — Tabes Dorsalis (Collins). 



The etiology of this disease is obscure. It is found in 
syphilis, in acute infectious diseases, in chronic metallic 
poisoning, and in injuries. 

Posterior sclerosis, tabes dorsalis, or locomotor ataxia, 
is a condition of sclerotic changes in the posterior columns. 
The present opinion is that it is the result of primary disease 
of the posterior nerve-roots. This is thought by many to 



492 A MANUAL OF PATHOLOGY 

depend generally upon syphilitic infection, but it occurs in 
traumatism and possibly in some of the infectious fevers. 
The lumbar portion is more commonly affected than the dor- 
sal, and lastly the cervical. The degeneration usually devel- 
ops in the lumbar cord, in the posterior nerve-roots. In the 
dorsal region there are also two areas of degeneration in 
the column of Burdach and in the cervical region; the chief 
involvement is in the columns of Goll. 

There is atrophy of the nervous tissue, with increase of the 
neurogha. The myelin sheaths break down and expose the 
axis-cylinders, which resist the degenerative processes longer 
than the other tissues. 

The lesions may not only affect the cord and peripheral 
nerves, but also involve areas in the brain and in the optic, 
oculomotor, and trigeminal nerves. 

There arc also degenerations nearly always present of the 
sensory nerve- endings. 

The main symptoms are girdle pains, loss of knee-jerk, 
Argyll-Robertson pupils, loss of sensation and tactile sense. 

Friedreich's disease, or hereditary ataxia, is a variety 
of posterior sclerosis that usually begins about the seventh 
year, and involves several members of a family. There is a 
hypoplasia of the cord or the cerebellum, and sclerosis of the 
posterior columns of the cord. The fibers in the column of 
Goll and the greater part of those in the column of Burdach 
degenerate, and the cells in the column of Clark are involved 
at times. There is also some degeneration of the direct cere- 
bellar tract and of the lateral pyramidal columns as well. 
The lesions are most marked in the lower part of the cord. 
>Acute anterior poliomyelitis is characterized by degen- 
eration and sclerosis of the anterior horns of the gray matter 
of the spinal cord. It occurs chiefly in children about three 
years old, but at times affects adults. 

The cause is unknown, but the processs is that of an acute 
inflammation. It is apparently either infectious or toxic in 
its origin and is distributed by the blood-vessels. The dis- 
ease usually begins rapidly, and is accompanied by chills and 
fever. 



DISEASES or THE SPINAL CORD 



493 



The lesions may be unilateral or bilateral, and are more 
common in the lumbar region. Early in the disease the 
blood-vessels of the anterior horns of the gray matter are 
distended, and the perivascular lymph-spaces filled with 
round-cells. Small interstitial hemorrhages may be present 
in the anterior horns. The gangHon-cells become larger, 
granular, and cloudy, often vacuolated, and altered in their 
staining reactions. The cells eventually become completely 
degenerated and disappear, the meduUated nerves lose their 
covering, and many are destroyed. Neuroghar hyperplasia 















Fig. 169. — Chronic Anterior Poliomyelitis (Collins). 



occurs in the involved areas, and the gray matter may become 
much indurated. 

Chronic anterior poliomyelitis or progressive muscu- 
lar atrophy occurs generally in adults, and is characterized 
by atrophy and disappearance of the motor cells of the ante- 
rior horns of the spinal cord. The small muscles of the hand 
are the first to undergo atrophy, then those of the arms, 
shoulders, and body. 

The diaphragm may become involved and death result. 
The change is one of fatty degeneration. 



494 A MANUAL OF PATHOLOGY 

The lesions generally appear in the cervical and upper 
dorsal portions of the cord, and extend along the anterior 
cornua in both directions. When the medulla is affected, the 
resulting condition is known as hulhar palsy. 

Bulbar palsy is similar to the above except that it occurs 
in the medulla instead of in the cord, and affects the ganglia 
of the hypoglossus, glossopharyangeal, spinal accessory, 
vagus, facial, abduccns, and motor portion of the trigeminus, 

Amyotrophic lateral sclerosis is a disease in which 







"^v 






Fig. 170. — Combined Posterior and Lateral Sclerosis (Collins). 

there is a degeneration of the peripheral motor nerves as well 
as an atrophy of the motor cells in the anterior horns of the 
gray matter of the cord. There is also more or less degenera- 
tion of the pyramidal columns. The muscles undergo the 
same changes as in progressive muscular atrophy. 

The degenerations begin in the sacral and lumbar por- 
tions of the cord and extend upward. 

Secondary Degenerations of the Spinal Cord.— The 
microscopic changes are those that have already been de- 



DISEASES OF THE SPINAL CORD 495 

scribed. The degenerations result from lesions in the brain 
or cord, and when in the cord are described as either ascend- 
ing or descending, according to the tracts affected. 

Descending degeneration is the usual result of disease of 
the cerebral cortex and internal capsule. It involves the 
motor tracts and the anterior and lateral pyramidal columns. 
If the lesion is unilateral and above the decussation, the 
anterior tract on the same side and the lateral pyramidal 
tract on the opposite side v^ill be affected. 

Ascending degeneration usually follows transverse myelitis 
and involves the sensory tract, the posterior columns below, 
and the columns of Goll above. 

THE PERIPHERAL NERVES 

Atrophy may result from pressure, from inflammation, 
or from an interruption in the continuity of the nerve. The 
myelin sheaths undergo degeneration, and later on the axis- 
cylinders break down. 

Degeneration of the nerves is with difficulty separated 
from inflammation. When non-inflammatory, is a simple 
degeneration; otherwise an inflammatory degeneration. The 
inflammatory ones are known as parenchymatous neuritis, 
in contradistinction to the interstitial, which involve the nerve- 
sheaths. 

Degeneration is found in injuries, in infectious diseases, 
and in intoxications. Certain nerves or sets of nerves may be 
involved in the different conditions, as those of the pharynx 
in diphtheria, those supplying the extensor muscles of the 
forearm in lead-poisoning, or the cord in syphihs. 

The degenerative changes may appear within twenty-four 
hours after an injury. The myelin sheaths become granular 
and cloudy, and finally break down into droplets. Larger 
drops form, fatty degeneration occurs, and leukocytes make 
their appearance. The axis- cylinders resist for a longer time, 
but they become nodular, vacuolated, and break up. The 
degeneration occurs more rapidly in the distal than in the 
proximal end. Regeneration may take place, but the nerve 
is usually replaced by a cord of fibrous tissue. 



49^ A MANUAL OF PATHOLOGY 

Neuritis. — The so-called parenchymatous neuritis is a 
degeneration of the nerve-fibers without involvement of the 
connective tissue. Interstitial neuritis is a true inflamma- 
tory process affecting the connective tissue. 

Acute interstitial neuritis is due to the same causes as bring 
about the degenerations. It is characterized by an exuda- 
tion into the endoneurium and perineurium. There are 
edema and congestion, v^ith an infiltration of round-cells and 
at times pus-cells. At the same time there is commonly 
degeneration of the nerve-fibers. The nerves are swollen 
and reddened. 

Chronic neuritis is interstitial and follows an acute attack, 
or is due to various infections and intoxications, as chronic 
lead- or alcohol-poisoning. There is a marked hyperplasia 
of the connective tissue, with associated degeneration and 
atrophy of the nerve-fibers. 

Tuberculosis of the nerves is due to secondary involve- 
ment through extension. The roots of the nerves are gen- 
erally affected. There arc a hyperplasia of the connective 
tissue and a secondary degeneration of the nerve-fibers. 

Syphilis of the nerves occurs commonly in the nerve-roots. 
It is characterized by a round-cell infiltration at first, and 
later by a marked hyperplasia of connective tissue, asso- 
ciated with atrophy and degeneration. Gummata have been 
observed in the cranial nerves. 

Leprosy of the nerves is characterized by nodular lesions 
along their course. There is a proliferation of the bacilli, 
with the formation of nodes in the fibers, accompanied by 
cellular infiltration with connective- tissue hyperplasia and 
degenerations. The lepra bacilli can be found within the 
tissues. 

Tumors. — Neuromata are the most frequent form of 
them, the jalse neuroma, which is more common than the 
true, is a growth taking place within the connective tissue 
of the nerve; it is similar to a fibroma. 

Sarcomata occur, but are rare. 

The malignant tumors may occur as secondary growths. 



NDEX 



Abbott's method of spore staining 

254 
Abdomen, post-mortem examina- 
tion, 208 
Abdominal pregnancy, 426 
Abnormalities of secretion, 28 
Abscess, definition of, 78 

embolic, 78 

metastatic, 78 

of Covvper's gland, 420 

perinephritic, 403 

perirectal, 343 

pyemic, 78 
Acetic acid for maceration, 223 
Acetone in blood and urine, 7,2 
Achlorhydria, 27 
Achorion schoenlenii, 141 
Acrania, 476 
Acromegaly, 29 
Actinomyces, 145 

bovis, 177 

madura?, 178 
Actinomycosis, 177 

of bone, 448 

of intestine, 352 

of liver, 367 

of lung, 307 

of lymph-nodes, 467 

of mouth, 316 

of muscle, 456 

of stomach, 331 

of thyroid, 458 
Addison's disease, 29 
Adenocarcinoma, 127 

of stomach, ;^7,^ 

of uterus, 433 
Adenocystoma, 120 
Adcnofibroma of mammary gland, 

440 
Adenoma, 118 

of adrenals, 459 
32 



Adenoma of intestine, 352 

of kidney, 400 

of larynx, 286 

of liver, 368 

of lungs, 308 

of mammary gland, 440 

of mouth, 316 

of pituitary body, 484 

of stomach, 331 

of testicle, 415 

of thyroid, 458 

of uterus, 433 
Adenomatous goitre, 457 
Adenosarcoma of ovary, 424 

of uterus, 433 
Adhesive inflammation, 85 
Adipocere, 55 
Adrenals, diseases of, 458 

malformation of, 458 

secretion of, abnormalities of, 29 
Aerobic organisms, 148 
Aerogenic tuberculosis, 300 
Aerogcns, 150 

^stivo-autumnal parasite, 187 
Agar-agar, 246 
Agglutinins, 140 
Alcohol for hardening, 224 
Alexin, 136, 138 
Algor mortis, 72 
Alum carmin, 237 

hcmatoxyUn solution, 236 
Alveolar sarcoma, 104 
Amboceptor, 138 
Amebic dysentery, 343 
Amitosis, 88 
Amoeba coH, 185 
in liver, 370 
Amphitrica, 146 
Amyloid changes in stomach, 330 

degeneration of adrenals, 459 
of intestine, 338 



497 



498 



INDEX 



Amyloid degeneration of kidney, 389 
of liver, 359 
of muscle, 454 
of pancreas, 378 
of uterus, 429 

disease of lymph-nodes, 464 
of spleen, 462 

metamorphosis, 59 
Amylopsin, 27 

Amyotrophic lateral sclerosis, 494 
Anabolic metabolism, 26 
Anabolism, 26 
Anaerobic cultures, 251 

organisms, 148 
Anaphase, 90 
Anasarca, 49 

Anchylostoma duodenalis, 202 
Anemia, local, 39 

of bone-marrow, 469 

of brain, 478 

of kidneys, 386 

of liver, 354 

of lungs, 288 

of lymph-nodes, 464 

of mouth, 313 

of muscle, 453 

of pia and arachnoid, 472 

of spinal cord, 486 

of spleen, 459 

of stomach, 326 

pernicious, 259 
Anemic infarct, 48 
Anencephaly, 476 
Anesthetic leprosy, 174 
Aneurysm, 277 
Angina ludovici, 323 
Angiocholitis, 370 
Angioma of liver, 367 

simplex, 115 
Angioneurotic edema, 49 
Angiosarcoma, 105 

of brain, 484 

of dura mater, 472 

of ovar}', 424 

of uterus, 453 
Anguillula intestinalis, 205 

stercoralis, 205 
Anilin gentian violet, 252 
Animal parasites and disease, 21 
Ankylosis, 450 
Anopheles, 187 
Anteflexion of uterus, 427 



Anteversion of uterus, 427 
Anthracosis, 65, 298 
Anthrax, bacillus of, 161 

of intestine, 352 

of stomach, 331 

symptomatic, bacillus of, 161 
Anti -bodies, 139 
Anti-enzymes, 140 
Antiseptics, 149 
Antitoxin, diphtheria, 158 
Aphthous stomatitis, 314 
Aplasia, 23, 51 
Apnea, 28 
Appendicitis, 341 
Aqueous alum hematoxylin solution, 

236 
Arachnoid, disease of, 472 

inflammation of, 473 
Arachnoidea, 206 
Argyria, 65 

Arnold's method of maceration, 222 
Arterial hyperemia, 37 

sclerosis, 36 
Arteries, changes within, 36 

diminished elasticity of, 36 

inflammation of, 274 

sclerosis of, 275 
Arteriocapillary fibrosis, 276 
Arterioliths, 44 
Arteriosclerosis, 275 

nodosa, 276 

of kidneys 387 
Arteritis, chronic, 275 

diffuse, 276 
Arthritis, 450 

deformans, 451 

neuropathic, 451 

rheumatoid, 451 

senile, 451 

uratica, 452 
Arthrospore, 148 
Articular rheumatism, 451 
Ascaris lumbricoides, 200 
Ascites, 49, 380 
Asiatic cholera, 345 
bacillus of, 166 
Aspergillus, 143 
Asphyxia, 28 
Assimilation of food, 27 
Association of bacteria, 149 
Ataxia, hereditary, 492 

locomotor, 491 



INDEX 



499 



Atelectasis, 290 
Atheroma, 276 
Atheromatous cyst, 276 
Atresia of uterus, 426 
Atrophic cirrhosis of liver, 362 

rhinitis, 283 
Atrophy, 51 

brown, 39, 52 

of bone-marrow, 469 

of bones, 445 

of kidneys, 385 

of liver, 360 

of lymph-nodes, 464 

of mammary gland, 439 

of muscles, 454 

of nerves, 495 

of pancreas, 377 

of prostate, 416 

of spleen, 461 

of stomach glands, 330 

of testicles, 413 

of thyroid, 457 

of uterus, 429 

progressive muscular, 454, 493 

pseudohypertrophic muscular, 454 
Attraction sphere, 86 
Atypical tumor, 97 
Auricular septum, incomplete, 256 
Autointoxication, 20 
Autopsy, technic of, 207 
Autosite, 25 



Bacillus acrogenes capsulatus, 165 

anthracis, 160 

coli communis, 165 

definition of, 146 

diphtherias, 157 

influenzae, 162 

leprae, 172 

mallei, 176 

oedcmatis maligni, 161 

of symptomatic anthrax, 161 

pectis, 165 

pneumoniae, 156 

pyocyaneus, 153 

tetani, 155 

tuberculosis, 169 

typhosus, 164 
Bacony metamorphosis, 59 
Bacteria, 144 

and disease, 21 



Bacteria, conditions of growth, 148 

multiplication of, 148 

products of, 149 

specific, 152 

staining of, 251 
Bacteriaceas, 144 
Bacteriologic methods, 246 
Bacteriolysins, 140 
Bacteriolysis, 140 
Bacterioproteins, 150 
Balanitis, 412 
Balanoposthitis, 412 
Barbers' itch, 142 
Barometric pressure, effect of, 20 
Basedow's disease, 29, 457 
Basidiomycetes, 141 
Basophile, 258 
Beef tapeworm, 195 
Beggiatoa, 146 
Bcggiatoaceae, 145 

Bichlorid of mercury for fixation, 226 
Bile, abnormalities of, 32 
Bile-ducts, inflammation of, 370 

stenosis of, 371 
Biliary cirrhosis of liver, 364 
Bilirubin, 32, 63 
Biliverdin, 32, 63 
Bismarck brown, 239 
Bladder at autopsy, 216 

calculi, 406 

dilatation of, 404 

exstrophy of, 404 

fistulae of, 405 

hemorrhage of, 405 

hyperemia of, 405 

hypertro[)hy of, 404 

malformations of, 404 

rupture of, 405 

syphilis of, 406 

tuberculosis of, 406 

tumors of, 409 
Blastomycetes, 144 
Blasts, 189 
Blood casts, 397 

changes in quality of, 37 
in quantity of, 37 

description of, 256 

diseases of, 259 

plates, 259 

staining, 243 
Blood-serum, 247 
Blood-vessels, repair of, 82 



SOO 



INDEX 



Bone, actinomycosis of, 448 

atrophy of, 445 

embolism of, 443 

fractures of, 449 

hemorrhage of, 443 

hyperemia of, 443 

hypertrophy of, 445 

inflammation of, 445 

leprosy of, 448 

necrosis of, 445 

repair of, 82 

syphilis of, 448 

thrombosis of, 443 

tuberculosis of, 447 

tumors of, 448 
Bone-marrow, diseases of, 468 
Borax carmin, 238 
Bouillon, 246 

Bowhill's method of staining, 255 
Brain, anemia of, 478 

cysticercus of, 484 

degenerations of, 480 

diseases of, 470 

edema of, 478 

embolism of, 480 

hemorrhage of, 479 

hyperemia of, 478 

inflammation of, 481 

malformations of, 476 

post-mortem examination of, 217 

sarcoma of, 484 

sclerosis of, 482 

softening of, 480 

syphilis of, 483 

thrombosis of, 480 

tuberculosis of, 483 

tumors of, 483 
Breast, diseases of, 437. See also 

Mammary gland. 
Bright's disease, 390 
Bronchi, dilatation of, 288 

inflammation of, 286 

obstruction of, 288 

tumors of, 288 
Bronchiectasis, 287 
Bronchitis, 286 

fibrinous, 287 
Bronchoblennorrhea, 286 
Bronchopneumonia, 295 
Bronchorrhea serosa, 286 
Brown atrophy, 39, 52 
of heart, 269 



Brown atrophy of muscle, 454 

Bubo, 465 

Bubonic plague, bacillus of, 165 

Bulbar palsy, 494 

Burn, 18 

Bursa?, diseases of, 453 

Bursitis, 453 



Cachexia, 27 
Calcareous infiltration, 65 
Calcification, 65 

of kidney, 390 

of lymph-nodes, 464 

of muscle, 454 

of spleen, 463 

of stomach, 330 

of thrombi, 44 
Calculi, biliary, 371 

in pancreatic duct, 380 

of ureter, 404 

prostatic, 419 

renal, 402 

salivary, 323 

vesical, 406 
Callus, 449 

Cancer. See Carcinoma. 
Capsules, staining of, 255 
Carbohydrates, metabolism of, 27 
Carbol-fuchsin, 252 
Carcinoma, 121 

of adrenals, 459 

of bladder, 410 

of bone, 449 

of intestine, 352 

of kidney, 400 

of liver, 368 

of lungs, 307 

of lymph-nodes, 468 

of mammary gland, 440 

of muscle, 456 

of nose, 283 

of ovary, 423 

of pancreas, 379 

of penis, 413 

of peritoneum, 383 

of pleura, 312 

of prostate, 420 

of stomach, 331 

of testicle, 415 

of thyroid, 458 

of uterus, 434 



INDEX 



501 



Carcinoma of vagina, 436 

of vulva, 437 
Caries of teeth, 317 
Carnification of lung, 290 
Cartilage, repair of, 82 
Caruncle of vulva, 437 

urethral, 411 
Caseous necrosis, 69 
Casts, epithelial, 597 

granular, 397 

hyaline, 397 

leukocytic, 397 

renal, 397 

tube, 397 

waxy, 397 
Catabolic metabolism, 26 
Catarrhal enteritis, 339 

pneumonia, 295 

stomatitis, 313 
Causes of disease, 18 
Caustics, effect of, 20 
Cavernous angioma, 115 
Cecum, inflammation of, 341 
Cell, 85 

function of, 87 
Cell-division, 85 

Celloidin method of imbedding, 230 
Cementoma, 116 
Centrosome, 86 
Cephalhematoma, 470 
Cephalocelc, 476 
Cercomonas intcstinalis, 186 
Cerebrospinal meningitis, 474 
Cervix, erosion of, 432 

lacerations of, 432 

uteri, stenois of, 426 
Cestodes, 192 
Chalicosis, 65, 298 
Chancre, 180 
Chancroid of vulva, 437 
Chemotoxins, 76 
Chlamydobacteriaceoe, 145 
Chloroma, 106 

of ])onc, 449 
Chlorosis, 261 
Cholangitis, 370 
Cholecystitis, 371 
Cholelithiasis, 371 
Cholera, Asiatic, 345 

bacillus of, 166 
Chondritis, laryngeal, 284 
Chondroma, 11 1 



Chondroma of bone, 448 

of lungs, 307 

of ovary, 423 

of testicle, 415 
Chondrosarcoma, 106 
Chorio-epithelioma, 131, 434 
Chromatin, 85 

Chromic acid for decalcification, 228 
Chromogens, 150 
Chromosomes, 88 
Chylous ascites, 381 
Cicatrization, 79 
Ciliary movement, 87 
Circulation, weakened, 35 
Circulatory disorders, 35 
Cirrhosis of liver, atrophic, 362 
biliary, 364 
hypertrophic, 362 
Cladothrix, 145 
Cleft palate, 313 
Cloaca of bone, 447 
Clostridium, 148 
Cloudy swelling, 52 
of kidney, 388 
of liver, 358 
of muscle, 453 
Coagulation necrosis, 68 
Coccaceaj, 144 
Coccidium oviforme, 1S5 

in liver, 370 
Coffee-grounds vomit, 327 
Cohnheim's theory of tumor forma- 
tion, 94 
Cold abscess of bone, 447 

effects of, 19 
Colitis, 342 
CoUes' law, 181 
Colliquation necrosis, 69 
Colloid metamorphosis, 58 
Colon, inflammation of, 342 
Colpitis, 435 
Complement, 138 
Concretions of prostate, 419 

salivary, 323 
Condyloma latum, 181 

of penis, 413 
Congenital malformation, varieties 

of, 23 
Congestion, hypostatic, 36 
Conidia, 141 

Connective tissue stains, 242 
Constipation, 34 



502 



INDEX 



Copremia, 34 

Coprostasis, 34 

Cor villosum, 267 

Cord. See also Spi)ial Cord. 

Corpora amylacea, 61, 419 

Coryza, 282 

Cover-glass preparations, staining of, 

251 
Cowper's glands, diseases of, 420 
Craniotabes, 443 
Crenothrix, 145 
Crescents of Laveran, 188 
Cretinism, 29 
Croupous pneumonia, 292 
Cryptorchia, 413 
Culture media, 246 

sterilization of, 249 
Cultures, forms of, 249 
Curschmann's spirals, 287 
Cutting sections, 233 
Cyanosis, 28 
Cyanotic induration of kidney, 386 

of lung, 289 
Cylindroma, 105 
Cystic adenoma of ovary, 422 ' 

goitre, 457 
Cystin calculi, 408 
Cystitis, 405 

phlegmonous, 406 

pseudomembranous, 405 
Cystocele, vaginal, 435 
Cystoma of ovary, 422 
Cysts, 132 

atheromatous, 276 

dermoid, 131 

of bladder, 410 

of Fallopian tube, 425 

of kidney, 401 

of liver, 369 

of mammary gland, 442 

of mouth, 317 

of pancreas, 379 

of peritoneum, 384 

of pia, 476 

of pituitary body, 485 

of prostate, 420 

of spinal cord, 490 

of testicle, 415 

of uterus, 434 

of vagina, 436 

ovarian, 421 

salivary, 323 



Cytolysins, 139 
Cytoplasm, 85 



Death, 71 

signs of, 72 
Decalcification, 227 
Decidupma malignum, 310 
Decomposition, 73 
Defects of development, 22 
Degenerations, 52. See also Mela- 
morphosis. 

of brain, 480 

of kidney, 388 

of muscle, 453 

of nerves, 495 

of testicle, 415 

parenchymatous, 52 
Delafield's hematoxylin, 236 
Dendritic tumor, 97 
Dermoid cyst, 131 
of ovary, 422 
of scrotum, 413 
of testicle, 415 
Development, defects of, 22 
Diabetes, 30 

mellitus and hyaline degeneration 
of pancreas, 379 
Diacetic acid in blood and urine, 32 
Diapcdesis, 76 

hemorrhage by, 40, 41 
Diarrhea, 34 
Diasters, 90 

Dibothriocephalus latus, 195 
Dilatation of Ijladder, 404 

of bronchus, 287 

of esophagus, 324 

of heart, 274 

of intestine, 336, 337 

of stomach, 331 

of uterus, 428 
Diminished cardiac action, 35 
Diphtheria, 320 

antitoxin, 158 

bacillus, 157 

laryngeal, 284 

nasal, 283 

pharyngeal, 320 
Diphtheritic inflammation, 83 

pharyngitis, 320 
Diplococcus intracellularis meningi- 
tidis, 154, 473 



INDEX 



S03 



Diplococcus pneumoniae, 155 
Disorders, circulatory, 35 

of metabolism, 28 
Dissecting aneurysm, 278 
Disseminated sclerosis of cord, 490 
Distoma hematobium, 199 

hepaticum, 198 

in liver, 370 

lanceolatum, 198 

pulmonare, 199 
Diverticulum, esophageal, 324 

intestinal, 334 

Meckel's, 334 
Double monsters, 24 

staining, 240 
Dropsy, 49 

Ductless glands, diseases of, 457 
Ductus arteriosus, persistent, 265 
Dunham's peptone solution, 248 
Duodenitis, 340 

Duodenum, inflammation of, 340 
Dura mater, hemorrhage of, 470 
hyperemia of, 470 
inflammation of, 470 
syphilis of, 471 
thrombosis of, 470 
tuberculosis of, 471 
tumors of, 471 
Dysentery, 343 

ameba of, 185 

amebic, 343 

bacterial, 344 

diphtheritic, 344 
Dysmenorrhea membranacea, 429 
Dyspnea, 28 



Ebner's fluid, 228 
Ecchondroma, in 
Ecchymoses, 41 
Echinococcus cysts of liver, 369 

endogenes, 196 

exogcnes, 197 

hydatidosus, 196 

multilocularis, 197 

of lungs, 308 

scoleciparius, 196 
Eclampsia, 31 
Edema, 49 

of arachnoid and pia, 473 

of brain, 478 

of glottis, 284 



Edema of intestine, 338 

of kidney, 398 

of larynx, 284 

of liver, 359 

of lung, 289 
Edematous infiltration, 62 
Ehrlich's lateral-chain theory, 136 

triacid stain, 244 
Elastic fiber stain, 243 
Electricity, effects of, 19 
Elephantiasis of scrotum, 413 

of vulva, 437 
Emboli, varieties of, 46 
Embolic abscess, 78 
Embolism, 46 

cerebral, 480 

crossed, 47 

of bone, 443 

of brain, 480 

of intestine, 338 

of kidney, 388 

of liver, 356 

of spleen, 460 

paradoxical, 47 

results of, 47 

retrograde, 46 
Emigration of leukocytes, 76 
Emphysema, interstitial, 50 

pulmonary, 290 
Empyema, 79, 311 
Encapsulation, 71 

of irritant material, 79 
Encephalitis, 481 

suppurative, 482 

toxic, 482 
Encephalomalacia, 480 
Enchondroma, in 
End products, 26 
Endarteritis, 274 

deformans, 276 

obliterans, 277 
Endocarditis, 269 

sclerotic, 271 

ulcerative, 271 

verrucose, 270 
Endogenous infection, 134 

intoxication, 20 
Endometritis, 430 

glandular, 431 

interstitial, 431 
Endospores, 148 
Endothelioma, 106 



504 



INDEX 



Endothelioma of brain, 484 
of dura mater, 472 
of lungs, 307 
of meninges, 475 
of ovary, 424 
of peritoneum, 3S3 
of pleura, 312 
Enteritis, 339 
catarrhal, ^^g 
follicular, 339 
suppurative, 339 
ulcerative, 340 
Enterocysts, 334 
Enteromycosis, 352 
Enzymes and bacteria, 151 
Eosin, 241 

and methylene blue, 244 
Eosinophil, 258 
Eosinophilia, 259 
Ependymitis, 478 
Epididymitis, 414 
Epispadias, 412 
Epistaxis, 41 
Epithelial casts, 397 

pearls, 125 
Epithelioid cells, 80 
Epithelioma of larynx, 286 
of uterus, 434 
squamous, 125 
Epithelium, repair of, 82 
Epulis, 109 
Erlicki's fluid, 226 
Erosion of cervix, 432 
Erythrasma, 143 
Erythrocytes, 256 
Esmarch tube, 250 
Esophagus, diverticula of, 324 
inflammation of, 324 
malformations of, 323 
perforation of, 325 
stenosis of, 324 
stricture of, 324 
tumors of, 325 
Etiology, definition of, 17 
Eustrongylus gigas, 201 
Exfoliation, 71 
Exogenous infection, 133 

intoxication, 20 
Exophthalmic goitre, 29, 457 
Exoplasm, 85 
Exostosis, 113 
Exstrophy of' bladder, 404 



Extraneous pigmentation, 64 
Extra-uterine pregnancy, 425 
Extravasation, 41 
Exudates, 49 

inflammatory, 77 
Exudation cysts, 132 



Fallopian tubes, hyperemia of, 424 
inflammation of, 424 
malformations of, 424 
syphilis of, 425 
tuberculosis of, 425 
tumors of, 425 
Farcy, 176 
Fat necrosis, 71 

of pancreas, 378 
Fats, metabolism of, 27 
Fatty degeneration of adrenals, 458 
of kidney, 388 
of liver, 358 
of testicles, 413 
of uterus, 429 
infiltration, 53 
of liver, 357 
of muscle, 454 
of pancreas, 378 
metamorphosis, 55 
of heart, 269 
of muscle, 454 
of stomach, 330 
Favus, fungus of, 141 
Fermentation, bacteria and, 150 
in intestine, 34 
in stomach, 34 
Fibrinous bronchitis, 287 
exudate, 77 
pneumonia, 292 
Fibro-adenoma, 119 

of mammary gland, 440 
Fibroblasts, 80, 81 
Fibroid tuberculosis, 303 

uterine, 432 
Fibroma, 107 
of bladder, 409 
of bone, 448 
of Fallopian tube, 425 
of kidney, 399 
of larynx, 286 
of liver, 368 
of lungs, 307 
of mammary gland, 439 



INDEX 



505 



Fibroma of meninges, 475 

of mouth, 316 

of nose, 283 

of ovary, 423 

of peritoneum, 383 

of spinal cord, 490 

of stomach, 331 

of testicle, 415 

of thyroid, 458 

of vagina, 436 

of vulva, 437 
Fibromyoma of Fallopian tube, 425 

of uterus, 432 

of vagina, 436 

of vulva, 437 
Fibrosarcoma, 103 
Fibrosis, arteriocapillary, 276 
Fibrous pneumonia, 296 
Filaria diurna, 202 

medinensis, 201 

nocturna, 202 

perstans, 202 

sanguinis hominis, 202 
Filariasis, 202 

Finkler-Prior spirillum, 167 
Fistula in ano, 343 
Fistulas, 78 

of bladder, 405 

salivary, 323 

vaginal, 435 
Fixation, 224 
Flagella, staining of, 254 
Flagellated bodies of malaria, 188 
Flemming's solution, 227 
Flies, 208 

Floating kidney, 385 
Follicular enteritis, 339 
Food, assimilation of, 27 
Foreign bodies in intestine, 353 
in larynx, 285 
in stomach, 334 
influence in disease, 21 
Formalin for hardening, 225 
Fractures, 449 
Fragilitas ossium, 445 
Freezing microtome, 233 
Friedreich's disease, 442 
Fungi, 141 
Fusiform aneurysm, 218 

Gabbet's methylene-blue, 252 
Gall-bladder, inflammation of, 371 



Gall-bladder, tumors of, 373 
Gall-stones, 371 
Ganglioma of brain, 483 
Gangrene, 69 

of lungs, 299 
Gangrenous pancreatitis, 377 

stomatitis, 315 
Gastrectasis, 331 
Gastritis, 327 

chronic, 329 

phlegmonous, 327 

pseudomembranous, 327 

sclerotic, 329 
Gastro-enteritis, 339 
Gastromalacia, 330 
Gastroptosis, 331 
Gelatin, 247 
Gentian violet, 239 
Germicides, 149 
Giant cells, 91 
Giant-cell sarcoma, 103 
Glanders, 175 

of larynx, 285 

of lungs, 307 

of lymph-nodes, 467 

of muscle, 456 

of nose, 283 

of stomach, 331 
Gleet, 411 
Glioma, 120 

of brain, 483 

of spinal cord, 489 
Glomerulonephritis, 392 
Glossitis, 316 
Glottis, edema of, 284 
Glucose bouillon, 246 

gelatin, 247 
Glycemia, 30 

Glycerin-albumin solution, 233 
Glycogen in kidney, 390 
Glvcogenic infiltration, 61 
Goblet cell, 58 
Goitre, 457 

adenomatous, 457 

cystic, 457 

exophthalmic, 29 

fibrous, 457 

parenchymatous, 457 
Goldhorn's stain, 244 
Gonorrhea, 410 
Gout, 31, 452 
Gram's method, 253 



5o6 



INDEX 



Granular casts, 397 

kidney, pale, 394 
red, 395 
Granulation tissue, 80 
Granulomata, specific, 169 
Graves' disease, 457 
Gray hepatization in pneumonia, 

294 
Green-stick fracture, 449 
Guinea worm, 201 
Gumma, 181 
Gums, tumors of, 316 
Gymnobacteria, 146 



Hanging-drop cultures, 251 

Hanot's cirrhosis, 362 

Hanseman's atrophy of pancreas, 

377 
Haptophorous group, 136 
Hardening, 224 
Harelip, 313 
Healing, 80 
Heart, brown atrophy of, 269 

dilatation of, 274 

disturbances of, activity of, 35 

fatty metamorphosis of, 269 

hypertrophy of, 272 

inflammation of, 267 

malformations of, 265 

opening of, at autopsy, 211 
Heat in blood-staining, 243 
Hemangioma, 115 
Hemarthrosis, 450 
Hematein, 237 
Hematogenous jaundice, 33 

pigments, 62 

tuberculosis, 305 
Hematoidin, 63 
Hematoma, 41 
Hematometra, 426 
Hematomyelia, 488 
Hematosalpinx, 424 
Hematoxylin, Delafield's, 236 

Ehrlich's, 236 

staining, 237 
Hematuria, 41 
Hemicrania, 476 
Hemoglobin, 62, 257 
Hemoglobinemia, 257 
Hemolysin, 139 
Hemolvsis, 21 



Hemopericardium, 265 
Hemophilia, 41 
Hemoptysis, 41, 289 

in tuberculosis, 306 
Hemorrhage, 40, 

by diapedesis, 40, 41 

by rhexis, 40, 41 

from adrenals, 459 

from bladder, 405 

from bone, 443 

from brain, 479 

from dura mater, 470 

from Fallopian tubes, 424 

from joints, 450 

from kidney, 387 

from liver, 357 

from lungs, 289 

from mammary gland, 438 

from muscle, 453 

from ovaries, 420 

from pia and arachnoid, 472 

from pleura, 309 

from spinal cord, 486 

from spleen, 460 

from stomach, 326 

from uterus, 429 

in typhoid fever, 348 

results of, 42 

spontaneous arrest of, 42 

within peritoneum, 380 
Hemorrhagic infarct, 41, 48 
Hemorrhoids, 280, 338 
Hepatitis, acute, 360 

chronic, 361 
Hepatization in pneumonia, 293 
Hepatogenous pigmentation, 63 
Hereditary ataxia, 492 

syphilis, 181 
Hermann's fluid, 227 
Hermaphroditism, 23 
Hernia, 334 
Heterologous tumor, 97 
Heteroplasia, 94 
Histoid tumor, 97 
Hob-nail liver, 362 
Hodgkin's disease, 264 
Homologous tumor, 97 
Homoplastic tumor, 97 
Horseshoe kidney, 385 
Hour-glass stomach, 326 
Hutchinson's teeth, 182 
Hyaline casts, 397 



INDEX 



507 



Hyaline degeneration of lymph- 
nodes, 464 
of muscle, 454 
of pancreas, 378 

metamorphosis, 56 
Hyaloplasm, 85 
Hydatid of Morgagni, 425 
Hydrarthrosis, 451 
Hydrocele, 50, 416 
Hydrocephalus, 50, 473, 476 
Hydrochloric acid for decalcifica- 
tion, 228 
for maceration, 243 
Hydrometra, 426 
Hydromyelia, 488 
Hydronephrosis, 401 
Hydropericardium, 50, 265 
Hydrosalpinx, 424 
Hydrothorax, 50, 309 
Hygroma, 471 
Hyperchlorhydria, 27 
Hyperchromatosis, 122 
Hyperemia, 37 

active, 37 

local, 37 

of bladder, 405 

of bones, 443 

of brain, 478 

of dura mater, 470 

of Fallopian tubes, 424 

of joints, 450 

of kidney, 386 

of liver, 354 

of lung, 288 

of lymph-nodes, 464 

of mammary gland, 438 

of mouth, 313 

of muscle, 453 

of ovaries, 420 

of pancreas, 374 

of peritoneum, 380 

of pia and arachnoid, 472 

of pituitary body, 484 

of pleura, 308 

of spinal cord, 486 

of spleen, 459 

of stomach, 326 

of thymus gland, 458 

of thyroid, 458 

of uterus, 428 

of vulva, 436 

passive, 39 



Hyperkeratosis, 125 
Hypernephroma, 120, 400, 458 

of liver, 368 
Hyperplasia, 93 

Hypertrophic cirrhosis of liver, 362 
Hypertrophy, 92 

etiology of, 92 

false, 93 

morbid anatomy, 93 

of bladder, 404 

of bone, 445 

of bone-marrow, 469 

of heart, 272 

of lymph-nodes, 464 

of mammary gland, 439 

of pituitary body, 484 

of prostate, 466 

of testicles, 413 

of thyroid, 457 

of uterus, 429 
Hypochlorhydria, 27 
Hypoplasia, 23, 51 
Hypospadias, 412 
Hypostatic congestion, 36 

pneumonia, 36 



Icterus, 32, 64, 373 
Imbedding methods, 229 
Immune body, 138 
Immunity, 134 

theories of, 135 
Inflammation, 74 

acute, 82 

adhesive, 83 

cardinal symptoms of, 76 

catarrhal, 83 

causes of, 74 

chronic, 82 

croupous, 83 

degenerative, 83 

desquamative, 83 

diphtheritic, 83 

exudative, 82 

fibrinous, 83 

gangrenous, 84 

hemorrhagic, 83 

infectious, 82 

interstitial, 83 

of appendix, 341 

of arteries, 274 

of bile-ducts, 370 



5o8 



INDEX 



Inflammation of bladder, 405 
of bone, 445 
of bone-marrow, 469 
of brain, 481 
of bronchi, 286 
of colon, 342 
of Cowper's gland, 420 
of duodenum, 340 
of dura, 470 
of ependyma, 478 
of esophagus, 324 
of Fallopian tubes, 424 
of gall-bladder, 371 
of heart-muscle, 267 
of intestine, '339 
of joint, 450 
of larynx, 284 
of liver, 360 

of lung, 292 See also Pneumonia. 
of lymphatics, 280 
of lymph-nodes, 465 
of mammary gland, 438 
of mouth, 313 
of muscle, 455 
of nerves, 496 
of nose, 282 
of ovaries, 421 
of pancreas, 375 
of pelvis of kidney, 402 
of penis, 412 
of pericardium, 265 
of pharynx, 319 
of pia and arachnoid, 473 
of pituitary body, 484 
of pleura, 310 
of prostate, 419 
of rectum, 342 
of salivary glands, 322 
of seminal vesicles, 416 
of spinal cord, 486 
of spleen, 461 
of stomach, 327 
of teeth, 317 
of testicles, 414 
of thymus gland, 468 
of thyroid, 458 
of tongue, 316 
of tonsils, 318 
of urethra, 410 
of uterus, 430 
of vagina, 435 
of vulva, 436 



Inflammation, parenchymatous, 83 

phlegmonous, 84 

productive, 84 

purulent, 83 

pustular, 83 

specific, 84 

termination, 78 

ulcerative, 83 

varieties, 82 

vesicular, 83 
Infarct, 47 

anemic, 48 

hemorrhagic, 41, 48 

of kidney, 387 

of liver, 357 

of lung, 289 
Infection, 133 

mixed, 134 
Infectious disease, definition of, 21 

myelitis, 487 
Infiltration, calcareous, 65 

definition of, 52 

edematous, 62 

glycogenic, 61 

pigmentary, 62 

serous, 62 

uratic, 67 
Influenza bacillus, 162 
Injection of specimens, 229 
Injuries of penis, 412 

of urethra, 411 
Intermediate body, 138 
Interstitial emphysema, 50 
Intestine, anthrax of, 352 

at autopsy. 212 

congestion of, 338 

dilatation of, 337 

disturbances in, 34 

edema of, 338 

embolism of, 338 

foreign bodies in, 353 

inflammation of, 339 

malformations of, 334 

obstruction of, 336 

parasites of, 353 

perforation of, 337 

stenosis of, 337 

syphilis of, 351 

thrombosis of, 338 

tuberculosis of, 350 

tumors of, 352 

ulcer of, 337 



INDEX 



509 



Intoxication, 30 
Intussusception, 336 
Intussusceptum, 336 
Intussuscipiens, 336 
Invagination of intestine, 336 
Inversion of uterus, 428 
lodin solution for maceration, 223 
Irritant poisons, effect of, 20 
Ischemia, 39 



Jaundice, 32, 64, 373 
Joints, diseases of, 450 
hemorrhage of, 450 
hyperemia of, 450 
inflammation of, 450 
luxation of, 450 
tuberculosis of, 453 
tumors of, 453 
syphilis of, 452 



Karyokinesis, 88 

Karyoplasm, 86 

Keloid, 109 

Kidney, amvloid degeneration of, 

389 
anemia of, 386 
arteriosclerosis of, 387 
at autopsy, 214 
atrophy of, 385 
calcification of, 390 
cloudy swelling of. 388 
cyanotic induration of, 386 
cysts of, 401 
edema of, 398 
embolism of, 388 
fatty degeneration of, 388 
floating, 385 
glycogen in, 390 
hemorrhage of, 387 
horseshoe, 385 
hyperemia of, 386 
infarcts of, 387 
inflammation of, 390 

of pelvis of, 402 
large white, 394 
malformations of, 385 
pale granular, 394 
parenchvmatous degeneration of, 

388 
pelvis of, inflammation of, 402 



Kidney, red granular, 395 
sclerosis of, 387 
stone in, 402 
syphilis of, 399 
thrombosis of, 388 
tuberculosis of, 398 
tumors of, 399 

Koch's laws, 21 

Kyphosis, 443 



Laboratory technique, 222 
Lacerations of cervix, 432 
Laennec's cirrhosis, 362 
Lardaceous metamorphosis. 
Large white kidney, 394 
Laryngitis, 284 
Larynx, diphtheria of, 284 

edema of, 284 

foreign bodies in, 285 

inflammation of, 284 

malformations of, 284 

syphilis of, 285 

tuberculosis of, 285 

tumors of, 286 
Leiomyoma, 113 

of kidney, 399 
Lepra cell, 173 
Leprosy, 172 

of bone, 448 

of intestine, 352 

of larynx, 285 

of liver, 367 

of lymph-nodes, 467 

of nerves, 496 

of nose, 283 

of testicle, 415 
Leptomeningitis, 473, 490 
Leukemia, 262 

bone-marrow in, 469 

of lymph-nodes, 467 

spleen in, 463 
Leukocytes, 257 

emigration of, 76 
Leukocytic casts, 397 
Leukocytosis, 259 
Leukopenia, 259 
Leukoplakia, 316 
Leukorrhea, 435 
Linin, 86 
Lipoma, 109 

of bone, 448 



59 



5IO 



INDEX 



Lipoma of Fallopian tube, 425 

of kidney, 399 

of liver, 369 

of lung, 307 

of mouth, 316 

of peritoneum, 383 

of stomach, 331 

of testicle, 415 

of vulva, 437 
Lipomatosis, 439 
Liquefaction cysts, 132 

necrosis, 69 
Lithium carmin, 238 
Lithopedion, 23, 426 
Litmus milk, 248 
Liver, actinomycosis of, 367 

amyloid degeneration of, 359 

anemia of, 354 

at autopsy, 215 

atrophy of, 360 

carcinoma of, 368 

cirrhosis of, atrophic, 362 
biliary, 364 
hypertrophic, 362 

cysts of, 369 

edema of, 359 

embolism of, 356 

enlargement of, 358 

fatty degeneration of, 358 
infiltration of, 357 

fluke, 198 

hemorrhage of, 357 

hob-nail, 362 

hyperemia of, 354 

infarction of, 357 

inflammation of, 360 

leprosy of, 367 

malformations of, 354 

necrosis of, 356 

nutmeg, 356 

parasites of, 370 

parenchymatous degeneration of, 
358 

pigmentation of, 357 

rupture of, 365 

syphilis of, 366 

thrombosis of, 356 

tuberculosis of, 365 

tumors of, 367 
Livores mortis, 72 
Lobar pneumonia, 292 
Lobulation of kidneys, 385 



Local anemia, 39 

Locomotor ataxia, 491 

LoefHer's method of staining, 254 

methylene blue, 252 

mixture, 247 
Lophotricha, 146 
Lordosis, 444 
Lugol's solution, 223 
Lungs, actinomycosis of, 307 

anemia of, 288 

at autopsy, 212 

collapse of, 290 

edema of, 289 

emphysema of, 290 

fluke, 308 

gangrene of, 299 

glanders of, 307 

hemorrhage from, 289 

hyperemia of, 288 

infarction of, 289 

inflammation of, 292. See also 
Pneumonia. 

parasites of, 308 

syphilis of, 306 

tuberculosis of, 300 

tumors of, 307 
Luxation of joints, 450 
Lymphadenitis, 465 
Lymphadenoma, 467 
Lymphangiectasis, 281 
Lymphangioma, 115 
Lymphangitis, 280 
Lymphatic leukemia, 262, 264 
Lymphatics, inflammation of, 280 

syphilis of, 281 

tuberculosis of, 281 
Lymph-nodes, actinomycosis of, 467 

anemia of, 464 

carcinoma of, 468 

degenerations of, 464 

hyperemia of, 464 

hypertrophy of, 464 

in pseudoleukemia, 468 

inflammation of, 465 

leprosy of, 467 

sarcoma of, 468 

syphilis of, 466 

tuberculosis of, 466 

tumors of, 467 
Lymphocyte, 258 
Lymphocytosis, 259 
Lymphogenic tuberculosis, 305 



INDEX 



511 



Lymphoma, 467 

of thymus gland, 468 
Lymphosarcoma, loi, 467 
Lysis, 140 



Maceration, 222 
Macrocephaly, 476 
Macrocheilia, 317 
Macrocytes, 256 
Macrogametocyte, 189 
Macroglossia, 317 
Macrophage, 136 
Madura foot, 178 
Malaria, plasmodium of, 187 
Malformations, 22 

congenital varieties, 23 

of adrenals, 458 

of bladder, 404 

of brain, 476 

of esophagus, 323 

of Fallopian tubes, 424 

of heart, 265 

of intestine, 334 

of kidneys, 385 

of larynx, 284 

of liver, 354 

of mammary gland, 437 

of nose, 282 

of ovaries, 420 

of pancreas, 374 

of penis, 412 

of peritoneum, 380 

of scrotum, 413 

of spleen, 459 

of stomach, 326 

of teeth, 317 

of thymus gland, 468 

of thyroid, 457 

of trachea, 286 

of urethra, 410 

of uterus, 426, 427 

of vagina, 434 
Mallory's anilin blue stain, 242 
Mammary gland, adenoma of, 440 
atrophy of, 439 
carcinoma of, 440 
cysts of, 442 
fibroma of, 439 
hemorrhage from, 438 
hyperemia of, 438 
hypertrophy of, 439 



Mammary gland, inflammation of, 
438 
malformations of, 437 
sarcoma of, 439 
supernumerary, 437 
syphilis of, 439 
tuberculosis of, 439 
tumors of, 439 
Marasmus, 27 
Marrow, diseases of, 468 
Mast cells, 80 
Mastitis, 438 
Mayer's hematein, 237 
Meckel's diverticulum, 334 
Megaloblast, 257 
Megalocytes, 256 
Melaena neonatorum, 327 
Melanin, 64 
Melanoglossia, 316 
Melanosis, 64 

Melanotic sarcoma, 64, 104 
Meninges, cerebral, diseases of, 470 
Meningitis, basilar, 473 

cerebrospinal, 474 

cortical, 473 

spinal, 490 

tuberculous, 474 
Meningomyelitis, 488 
Menorrhagia, 429 
Mere, 189 

Metabolic pigmentation, 64 
Metabolism, disorders of, 26 
Metamorphosis, amyloid, 59 

colloid, 58 

definition of, 52 

fatty, 55 

hyaline, 56 

myxomatous, 57 
Metaphase, 89 
Metaplasia, 94 
Metastasis of tumors, 98 
Metastatic abscess, 78 
Metchnikoff's theory of immunity, 

135 
Meteorism, 353 
Methemoglobin, 257 
Methylene blue, Gabbet's, 252 

Loeffler's, 252 
Metritis, 430 
Metrorrhagia, 429 
Microblast, 257 
Microcephaly, 476 



512 



INDEX 



Micrococcus, 144 

gonorrhoeae, 153 
Microcytes, 256 ^ 
Microgametocvte, ^ ^u- ,• 
Micro-organisms, "^^^tiplication of, 
146 

specific, 152 
Microphage, 136 
Microsomes, 85 
Microspira, 145 ^^ 
Microsporon furfu ' -^ 

minutissimum, i •^ 
Microtome, freezirf' ^^■^ 
Miliary tubercle, 1,^'/^°^ 
Milk spots of hear ' '^ 
Mixed infection, i'^'^ 

leukemia, 262 r , . . 

Moeller's method °^ 'P^'^ stammg, 

Moniscumcontag^"'^^'^79 

fibrosum, 139 
Monotricha, 146 
Monsters, 22 

double, 24 

Montana spotted f^rf 'v-"^' f 
Morbid anatomy, c^.f^^tion of, 17 

physiology. defin''7°^' ^7 

Mosquito, malarial' ^ ^ 



yellow fever, 190, 
Mouth, actinomycc 



)sis of, 316 



anemia of muco^' membrane of, 

313 

cysts of, 317 

inflammation of, ^^^ 

syphilis of, 315 

tuberculosis of, 3' ^ 

tumors of, 316 
Mucin, 58 

Mucoid metamorp?'^^^^' 57 
Muco-pus, 77 
Mucor, 143 
Mucous patch, i8r 
Miiller's fluid, 225 
Multiple sclerosis, f^? ■ 
Multiplication of b?'^^"^' ^46 
Mummification, 69 
Mumps, 322 ,. f 

Muscle, amyloid def ""'^^^°" °f' 454 

anemia of, 453 

atrophy of, 454 

calcification of, 4- 

carcinoma of, 45( 



Muscle, degenerations of, 453 
fatty infiltration of, 454 

metamorphosis of, 454 
hemorrhage of, 453 
hyaline degeneration, 454 
hyperemia of, 453 
inflammation of, 455 
necrosis of, 453 
parasites of, 456 
repair of, 82 
sarcoma of, 456 
syphilis of, 456 
tuberculosis of, 456 
tumors of, 456 
Mycetoma, 178 
Mycobacteriacea^, 145 
Mycomycetes, 142 
Mycophylaxin, 136 
Mycosis fungoides, 179 
Mycosozin, 136 
Mycotic stomatitis, 314 
Myelitis, 486 
infectious, 487 
purulent, 487 
transverse, 487, 488 
traumatic, 487, 488 
varieties, 488 
Myelocyte, 258 

Myelogenous leukemia, 262, 263 
Myocarditis, 267 
Myofibroma of ovary, 423 
Myoma, 113 

of Fallopian tube, 425 
of liver, 368 
of stomach, 331 
sarcomatodes, 433 
Myosarcoma, 106 
Myositic fibrosa, 455 
Myositis, 455 
chronic, 455 
hemorrhagic, 455 
ossificans, 455 

progressiva, 456 
purulent, 455 
Myxangiosarcoma tubulare, 105 
Myxedema, 28 
Myxoma, 109 
of bone, 448 
of mouth, 316 
of testicle, 415 
Myxomatous metamorphosis, 57 
Myxosarcoma, 105 



INDEX 



513 



Nagana, 191 

Neck, post-mortem examination, 215 
Necrobiosis, definition of, 52 
Necrosis, 68 

caseous, 69 

coagulation, 68 

colliquation, 69 

fat, 71 

liquefaction, 69 

of bone, 445, 446 

of liver, 356 

of muscle, 453 

phosphorous, 447 
Nematodes, 199 

Neoplasms, 95. See also Tumors. 
Nephritis, 390 

acute diffuse, 393 
interstitial, 395 
parenchymatous, 391 

chronic interstitial, 395 
parenchymatous, 394 

effects of, 398 

interstitial, 390 

parenchymatous, 390 

suppurative, 395 
Nephrolithiasis, 402 
Nerves, atrophy of, 495 

degeneration of, 495 

inflammation of, 496 

tuberculosis of, 496 

tumors of, 496 
Nerve-tissue, repair of, 82 
Neuritis, 496 

Neuroglioma of brain, 483 
Neuroma, 114, 496 
Neuropathic arthritis, 451 
Neurosarcoma, 106 
Neutral carmin, 240 
Neutrophile leukocytes, 257 
Nipple, Paget's disease of, 442 
Nitric acid for decalcification, 228 
Nodular leprosy, 173 
Noma, 315 

pudendi, 437 
Normoblasts, 256 
Nose, diphtheria of, 283 

inflammation of, 282 

malformations of, 282 

syphilis of, 283 

tuberculosis of, 283 

tumors of, 283 
Nuclear jpice, 86 

33 



Nuclein, 85 
Nucleolus, 86 
Nucleus of cell, 85 
Nutmeg liver, 356 



Obesity, 28 

Obligatory parasite, 183 

Obstruction of intestine, 336 
of pancreatic duct, 379 

Odontoma, 116 

Oidium albicans, 142, 314 

Oligochromemia, 257 

Oligocythemia, 257 

Oophoritis, 421 

Optional parasite, 183 

Orchitis, 414 

Organization, 79 

Organoid tumor, 97 

Orth's solution, 225 

Osmic acid, 227 
solution, 223 

Osteitis, 446 

Osteoid sarcoma, 449 

Osteoma, iii, 448 
of lungs, 307 

Osteomalacia, 444 

Osteomyelitis, 445, 446, 469 

Osteophyte, 113 

Osteoporosis, 446 

Osteosarcoma, 106 

Osteosclerosis, 446 

Ostitis, 445 

Ovaries, cysts of, 421 
hemorrhage of, 420 
hyperemia of, 420 
inflammation of, 421 
malformations of, 420 
tumors of, 421, 423 

Oxaluria, 32 

Oxvuris vermicularis, 201 



Pachymeningitis, 470, 490 
Paget's disease of nipple, 442 
Palate, cleft, 313 
Pale granular kidney, 394 
Palsy, bulbar, 494 
Panarthritis, 450 

Pancreas, abnormalities of secretion 
of, 30 
amyloid degeneration of, 378 



514 



INDEX 



Pancreas at autopsy, 215 

atrophy of, 377 

carcinoma of, 379 

cysts of, 379 

fat necrosis of, 378 

fatty infiltration of, 378 

hyaline degeneration of, 378 

hyperemia of, 374 

inflammation of, 375 

malformations of, 374 

pigmentation of, 379 

sarcoma of, 379 

tuberculosis of, 377 

tumors of, 379 
Pancreatitis, acute hemorrhagic, 375 

chronic, 377 

gangrenous, 377 

interstitial, 377 

purulent, 377 

syphilitic, 377 
Papilloma, 117 

of bladder, 409 

of cervix, 433 

of Fallopian tube, 425 

of lar}-nx, 286 

of penis, 413 
. of vagina, 436 

of vulva, 437 
Paraffin method of embedding, 231 
Paramastitis, 438 
Parametritis, 430 
Paramoecium coli, 186 
Paramucin, 58 
Paranucleus, 87 
Paraphimosis, 412 
Parasites, 183 

of brain, 484 

of cerebral meninges, 476 

of dura mater, 472 

of intestine, 353 

of liver, 370 

of lungs, 308 

of muscle, 456 

of peritoneum, 384 

of spleen, 464 

of ureter, 404 

vegetable, 141 
Parasitic cyst, 132 
of uterus, 434 

monster, 25 

theory of cancer, 96 
Paratyphoid fever, 350 



Parenchymatous degeneration, 52 

of liver, 358 
Parostitis, 446 
Parotitis, 322 
Passive hyperemia, 39 
Pathogens, 150 
Pathology, definition of, 17 
Pelvis of kidney, inflammation of, 

402 
Penis, inflammation of, 412 

injuries of, 412 

malformations of, 412 

syphilis of, 413 

tuberculosis of, 413 

tumors of, 413 
Pentastomum denticulatum, 464 
Peptic ulcer of stomach, 329 
Perforation in typhoid fever, 348 

intestinal, 337 

of esophagus, 325 
Periarteritis, 275 
Pericarditis, 265 

purulent, 267 
Pericardium, diseases of, 265 

inflammation of, 265 
Perichondritis, laryngeal, 284 
Perihepatitis, 365 
Perimetritis, 430 
Perinephritic abscess, 403 
Periorchitis, 414, 416 
Periostitis, 445 

Peripheral nerves, diseases of, 495 
Periproctitis, 343 
Perithelioma, 105 

of brain, 484 

of meninges, 475 
Peritoneum, diseases of, 380 

hemorrhage within, 380 

hyperemia of, 380 

inflammation of, 381 

malformations of, 380 

parasites of, 384 

tuberculosis of, 383 

tumors of, 383 
Peritonitis, 381 
Peritricha, 146 
! Perityphlitic, 341 
[ Pernicious anemia, 259 

Petechiae, 41 
• Petri dish, 250 
; Pharyngitis, 319 
■ Pharynx, inflammation of, 319 



INDEX 



51S 



Pharynx, tumors of, 322 
Phimosis, 412 
Phlebitis, 279 
Phleboliths, 44 
Phlebosclerosis, 279 
Phlegmonous cystitis, 406 

gastritis, 327 
Phloroglucin, 228 
Phosphaturia, 32 
Phosphorous necrosis, 447 
Photogens, 150 
Phragmidiothrix, 145 
Phycomycetes, 143 
Phylaxin, 136 
Physometra, 426 
Pia mater, diseases of, 472 
inflammation of, 473 
syphilis of, 475 
Picric acid for decalcification, 228 

staining by, 241 
Picrolithium carmin, 238 
Pigeon-breast, 443 
Pigmentary infiltration, 62 
Pigmentation, extraneous, 64 

hematogenous, 62 

hepatogenous, 62 

metabolic, 64 

of adrenals, 459 

of bone-marrow, 469 

of intestine, 338 

of liver, 357 

of lymph-nodes, 464 

of pancreas, 379 

of spleen, 462 

of stomach, 330 
Pigmented sarcoma, loi 
Pituitary body and disease, 29 

diseases of, 484 
Pityriasis versicolor, 143 
Plague bacillus, 165 
Planococcus, 144 
Planosarcoma, 144 
Plasma cells, 80 
Plasmodium malariae, 187 
Pleura, hemorrhage from, 309 

hyperemia of, 308 

inflammation of, 310 

syphilis of, 312 

tuberculosis of, 312 

tumors of, 312 
Pleurisy, 310 
Pleuritis, 310 



Pleurogenic pneumonia, 299 
Plexiform angioma, 115 
Plimmer's bodies, 96 
Pneumonokoniosis, 296 
Pneumonia, 292 

aspiration, 295 

bacillus, 156 

catarrhal, 295 

croupous, 292 

fibrinous, 292 

fibrous, 294, 296 

hypostatic, 36, 292 

inspiration, 292 

lobar, 292 

pleurogenic, 299 

purulent, 298 

white, 306 
Pneumonomycosis aspergillana, 308 
Pneumothorax, 305, 309 
Podagra, 31 
Poikilocytes, 256 
Poison, definition of, 20 
Poliomyelitis, 488 

acute anterior, 492 

chronic anterior, 493 
Polychrome methylene-blue, 244 
Polycythemia, 257 
Polymastia, 437 

Polymorphonuclear leukocytes, 257 
Polymyositis, chronic disseminated, 

455 
Polyp, 97 

adenomatous, 120 
.nasal, 283 
Polypus of bladder, 409 
Polysarcia, 28 
Porencephaly, 476 
Pork tapeworm, 194 
Posterior sclerosis, 491 
Posthitis, 412 
Post-mortem examination, 207 

external inspection, 207 

internal inspection, 208 

of brain, 217 

of heart, 211 

of intestines, 213 

of kidneys, 214 

of liver, 215 

of lungs, 212 

of neck, 215 

of pancreas, 215 

of pelvic organs, 216 



5i6 



INDEX 



Post-mortem examination of spinal 
cord, 220 
of spleen, 213 
of stomach, 215 

lividity, 72 

rigidity, 72 
Potassium acetate for maceration, 

223 
Potato cultures, 248 
Precipitin, 139 

Pregnancy, extra-uterine, 425 
Procidentia uteri, 428 
Proctitis, 342 
Prof eta's law, 182 
Proglottides, 192 
Progressive muscular atrophy, 454, 

493 
Prolapse of rectum, 337 

of uterus, 428 

of vagina, 435 
Prophase, 88 
Prostate, atrophy of, 416 

concretions of, 419 

hypertrophy of, 416 

inflammation of, 419 

tuberculosis of, 419 

tumors of, 420 
Prostatitis, 419 
Proteids, metabolism of, 26 
Protoplasm, 85 
Protozoa, 185 
Psammoma, 106 
Psammosarcoma of brain, 486 
Pseudohypertrophic muscular atro- 
phy, 454 ■ 
Pseudoleukemia, 264 

infantum, 264 

lymph-nodes in, 467 

spleen in, 463 
Pseudomembrane in vagina, 435 
Pseudomembranous cystitis, 405 

enteritis, 340 

gastritis, 327 
Pseudomonas, 145 
Pseudomucin, 58 

cysts of ovary, 422 
Psoriasis linguee, 316 
Ptomains, 153 

intestinal, 34 
Ptyalin, 27 
Purulent exudate, 77 

pancreatitis, 377 



Purulent pericarditis, 267 

pleuritis, 311 

pneumonia, 298 
Pus, 77 

cells, 76 
Putrefaction, bacteria and, 150 
Pyelitis, 402 
Pyelonephritis, 403 
Pyemic abscess, 78 
Pylorus, cancer of, 332 
Pyometra, 426 
Pyomyelia, 489 
Pyonephrosis, 402, 403 
Pyopericardium, 79 
Pyopneumothorax, 312 
Pyosalpinx, 79, 424 
Pyrenin, 86 
Pyrosoma bigeminum, 191 



Quartan parasite, 187 



Rachitic rosary, 444 
Rachitis, 28, 443 
Ranula, 317, 323 
Receptors, 136 
Rectocele, vaginal, 435 
Rectum at autopsy, 216 

inflammation of, 342 

prolapse of, 337 
Red atrophy of liver, 356 

granular kidney, 395 

hepatization in pneumonia, 294 

softening of brain, 48 
of spinal cord, 487 

thrombus, 43 
Regeneration, 181 
Relapsing fever, spirillum of, 168 
Renal calculi, 402 
Repair, 80 

Reproduction, function of cell in, 87 
Resolution, 78 
Rests, 96 

Retention cysts, 132 
Retroflexion of uterus, 427 
Retrograde embolism, 46 
Retrogressive processes, 51 
Retroversion of uterus, 427 
Rhabdomyoma, 113 

of testicle, 415 
Rhabdosarcoma, 400 



INDEX 



517 



Rheumatism, acute articular, 451 

Rheumatoid arthritis, 451 

Rhexis, 40 

Rhinitis, 282 

Rhinoscleroma, 180 

Ribbert's theory of tumor formation, 

96 
Rice bodies, 453 
Rickets, 28, 443 
Rigor mortis, 72 
Rodent ulcer, 126 • 

Round ulcer of stomach, 329 

worms, 199 
Rupture of bladder, 405 

of liver, 365 

of uterus, 427 
Russell's bodies, 96 



Saccharomycetes, 144 
Saccular aneurysm, 277 
Safranin, 239 
Sago spleen, 462 
Salivary calculi, 323 

ducts, fistula; of, 323 

glands, inflammation of, 322 
tumors of, 323 
Salpingitis, 424 
Saprogens, 149 
Sarcina, 144, 146 
Sarcoma, 100 

alveolar, 104 

giant-celled, 103 

melanotic, 64, 104 

of adrenals, 459 

of bone, 448 

of brain, 484 

of dura mater, 471 

of Fallopian tube, 425 

of gums, 316 

of intestines, 352 

of kidney, 399 

of larynx, 286 

of lungs, 307 

of lymph-nodes, 468 

of mammary gland, 439 

of meninges, 475 

of mouth, 316 

of muscle, 456 

of nerves, 496 

of nose, 283 

of ovary, 243 



Sarcoma of pancreas, 376 

of peritoneum, 383 

of pituitary body, 484 

of pleura, 312 

of prostate, 420 

of spinal cord, 490 

of stomach, 331 

of testicle, 415 

of thyroid, 458 

of uterus, 433 

of vagina, 436 

of vulva, 437 

osteoid, 449 

round-celled, loi 

spindle-celled, loi 

varieties, loi 
Schizomycetes, 144 
Scirrhus of stomach, 332 
Sclerosis, amyotrophic lateral, 494 

arterial, 36, 275 

disseminated, 490 

of brain, 482 

of kidney, 387 

of spinal cord, 487 

posterior, 491 
Sclerotic endocarditis, 271 
Scoliosis, 443 
Scrotum, diseases of, 413 
Season, influence of, 20 
Seat worms, 201 
Secretion, abnormalities of, 28 
Section cutting, 233 
Seminal vesicles, diseases of, 416 
Senile arthritis, 451 
Septate vagina, 434 
Sequestra, 71, 445 
Serial sections, 234 
Sero-pus, 77 
Serous exudate, 77 

infiltration, 62 
Shadow corpuscles, 257 
Sialoliths, 323 
Siderosis, 65, 298 
Signet-ring appearance, 358 
Sinus, 78 

Slant cultures, 250 
Sleeping sickness, 191 
Slough, 71 
Softening of brain, 480 

of stomach, 330 
Somatic death, 72 
Sozin, 136 



5i8 



INDEX 



Specific granulomata, 169 
Spermatocele, 415 
Spermatolysin, 140 
Sphacelus, 71 
Spinal cord, anemia of, 486 

ascending degeneration of, 494 
descending degeneration of, 494 
hemorrhage of, 486 
hyperemia of, 486 
inflammation of, 486 
multiple sclerosis of, 490 
post-mortem examination of, 220 
sclerosis of, 487 
softening of, 487 
syphilis of, 489 
tuberculosis of, 489 
tumors of, 489 
meningitis, 490 
Spirillaceae, 145 
Spirillum, 145 

cholerae asiaticas, 166 
of Finkler-Prior, 167 
of relapsing fever, 168 
Spirochaeta, 145, 146 
pallida, 168 

and syphilis, 180 
Spirosoma, 145 

Spleen, amyloid disease of, 462 
anemia of, 459 
at autopsy, 213 
atrophy of, 461 
calcification of, 463 
embolism of, 460 
hemorrhage of, 460 
hyperemia of, 459 
in leukemia, 463 
in pseudoleukemia, 463 
inflammation of, 461 
malformation of, 459 
parasites of, 464 
pigmentation of, 462 
sago, 462 
syphilis of, 461 
thrombosis of, 460 
tuberculosis of, 461 
tumors of, 460, 464 
Splenitis, 461 
Splenization of lung, 290 
Splenomedullary leukemia, 263 
Spongioplasm, 85 
Spores, 148 
Staining of, 254 



Sporozoite, 189 

Sporozoon, 189 

Sporulation, 148 

Spotted fever, Montana, 191 

Squamous epithelioma, 125 

Stab cultures, 250 

Stain, Abbott's, 254 

Bowhill's, 255 

connective-tissue, 242 

Ehrlich's triacid, 244 

elastic fiber, 243 

Gabbet's methylene-blue, 252 

Goldhorn's, 244 

Gram's, 253 

Loeflfler's, for flagella, 254 
methylene-blue, 252 

Mallory's anilin blue, 242 

Moeller's, 254 

nuclear, 236 

Unna's orcein, 243 

Van Gieson's, 241 

Weigert's, 243 

Wright's, 244 
Staining, 234 

cover-glass preparations, 251 

difl'usc, 240 

double, 240 

of bacteria, 251 

of blood, 243 

of capsules, 255 

of flagella, 254 

of spores, 254 
Staphylococcus pyogenes albus, 152 
aureus, 152 
citreus, 152 
Starvation, 27 
Stasis, 39 
Steapsin, 27 
Stegomyia fasciata, 190 
Stenosis of bile-ducts, 371 

of cervix, 426 

of esophagus, 324 

of intestine, 337 

of uterine cavity, 428 

of vagina, 435 
Sterilization of culture media, 249 
Stomach, anemia of, 326 

at autopsy, 215 

atrophy of glands of, 330 

calcification of, 330 

cancer of, 331 

dilatation of, 331 



INDEX 



519 



Stomach, displacement of, 331 

foreign bodies in, 334 

hemorrhage of, 326 

hour-glass, 326 

hyperemia of, 326 

inflammation of, 327 

malformations of, 326 

round ulcer of, 329 

peptic ulcer of, 329 

pigmentation of, 330 

scirrhus of, ^,^,2 

softening of, 330 

syphilis of, 331 

thrombosis of, 327 

tuberculosis of, 331 
Stomatitis, 313 

aphthous, 314 

catarrhal, 313 

gangrenous, 315 

mycotic, 314 

syphilitic, 315 

ulcerative, 314 
Stone, gall-, 371 

prostatic, 419 

renal, 402 

vesical, 406 
Streptococcus, 144 
Stricture of esophagus, 324 
Strobile, 192 

Subarachnoid space, hemorrhage in- 
to, 472 
Sucking worms, 198 
Suflfusion, 41 
Sugillation, 41 
Suppuration, 78 
Suppurative encephalitis, 482 

enteritis, 339 

nephritis, 395 
Surra, 191 
Symptomatic anthrax, bacillus of, 

'161 
Syncytioma, 130 

malignum, 434 
Syphilis, 180 

hereditary, 181 

of adrenals, 459 

of bladder, 406 

of bone, 448 

of brain, 483 >/ 

of dura mater, 471 

of Fallopian tube, 425 

of intestine, 351 



Syphilis of joints, 452 

of kidney, 399 

of larynx, 285 

of liver, 366 

of lungs, 306 

of lymphatics, 281 

of lymph-nodes, 466 

of mammary gland, 439 

of mouth, 315 

of muscle, 456 

of nose, 283 

of penis, 413 

of pia mater, 475 

of pituitary body, 484 

of pleura, 312 

of spinal cord, 484 

of spleen, 461 

of stomach, 331 

of testicles, 415 

of thymus gland, 468 

of thyroid, 458 

of tonsils, 319 

of urethra, 411 

of uterus, 432 

of vagina, 436 

of vulva, 437 
Syphilitic pancreatitis, 377 
Syringomyelia, 489 



Tabes dorsalis, 491 
Taenia cucumerina, 198 

cchinococcus, 196 

elliptica, 198 

mediocanellata, 195 

nana, 197 

saginata, 195 

solium, 194 
Tapeworms, 192 
Tattoo marks, 65 
Technique, laboratory, 222 
Teeth, caries of, 317 

inflammation of, 317 

malformations of, 317 
Telophase, 90 

Temperature and bacterial growth, 
148 

effects of, 18 
Tendons, diseases of, 453 
Tenosynovitis, 453 
Teratoid tumor, 97, 131 
Teratoma, 131 



520 



INDEX 



Tertian parasite, 187 
Testicles at autopsy, 217 

atrophy of, 413 

fatty degeneration of, 413 

hypertrophy of, 413 

inflammation of, 414 

leprosy of, 415 

malformations of, 413 

syphilis of, 415 

tumors of, 415 
Test-tubes, filling of, 248 
Tetanus, bacillus of, 155 
Texas fever, 191 

parasite of, 191 
Thermophilic bacteria, 148 
Thiothrix, 145 
Thoma's method for decalcification, 

229 
Thorax, post-mortem examination, 

208 
Thread worm, 201 
Thrombi, 42 

classification of, 44 

liquefaction of, 44 

metamorphosis, 44 

i-ed, 43 

white, 43 
Thrombosis, 42 

cerebral, 480 

of bone, 443 

of brain, 480 

of dura mater, 470 

of intestine, 338 

of liver, 356 

of renal veins, 388 

of spleen, 460 

of stomach, 327 
Thrush, 142, 314 
Thymus gland, diseases of, 468 
Thyroid, atrophy of, 457 

gland and disease, 29 

hyperemia of, 458 

hypertrophy of, 457 

inflammation of, 458 

malformation of, 457 

secretion, abnormalities of, 28 
Thyroidin, 29 
Thyroiditis, 458 
Tinea favosa, 141 
Tongue, inflammation of, 316 
Tonsillitis, 318 

leptothricia, 319 



Tonsils, inflammation of, 318 
syphilis of, 319 
tuberculosis of, 319 
Tophi, 68 
Toxalbumins, 150 
Toxic encephalitis, 482 
Toxins, 140, 150 
Toxoids, 140 
Toxones, 140 
Toxophorous group, 136 
Toxophylaxin, 136 
Toxosozin, 136 

Trachea, malformation of, 286 
Transverse myelitis, 487, 488 
Traumatic myelitis, 487, 488 
Traumatism, efl"ects of, 18 
Trematodes, 198 
Trichina spiralis, 205 
Trichloracetic acid, 229 
Trichobacteria, 146 
Trichocephalus dispar, 205 
Trichomonas intestinalis, 186 

vaginalis, 187 
Trichophyton tonsurans, 142 
Triplets, 24 
Trypanosomes, 190 
Tse-tse fly disease, 191 
Tube casts, 397 
Tubercle, miliary, 169 
Tubercular pericarditis, 267 
Tuberculosis, 169 

acute caseous, 302 

aerogenic, 300 

chronic ulcerative, 303 

fibroid, 303 

hematogenous, 305 

lymphogenic, 305 

miliary, 305 

of adrenals, 459 

of bladder, 406 

of bone, 447 

of brain, 483 

of bursae, 453 

of dura mater, 471 

of Fallopian tube, 425 

of intestine, 350 

of joints, 452 

of kidney, 398 

of larynx, 285 

of liver, 365 

of lungs, 300 

of lymphatics, 281 



INDEX 



521 



Tuberculosis of lymph-nodes, 466 

of mammary gland, 439 

of mouth, 315 

of muscle, 456 

of nerves, 496 

of nose, 283 

of pancreas, 377 

of penis, 413 

of peritoneum, 383 

of pia, 474 

of pituitary body, 484 

of pleura, 312 

of prostate, 419 

of seminal vesicles, 416 

of spinal cord, 489 

of spleen, 461 

of stomach, 331 

of tendons, 453 

of testicles, 414 

of thymus gland, 468 

of thyroid, 458 

of tonsils, 319 

of urethra, 411 

of uterus, 432 

of vagina, 436 

of vulva, 437 

pulmonary, 300 
Tuberculous meningitis, 474 
Tumors, 95 

benign, 98 

classification of, 99 

death from, 98 

malignant, 98 

morphology of, 97 

of adrenals, 459 

of bladder, 409 

of bone, 448 

of brain, 483 

of bronchi, 288 

of dura, 471 

of esophagus, 325 

of Fallopian tube, 425 

of gall-bladder, 373 

of intestine, 352 

of joints, 453 

of kidney, 399 

of larynx, 286 

of liver, 367 

of lung, 307 

of lymph-nodes, 467 

of mammary gland, 439 

of mouth, 316 



Tumors of muscle, 456 

of nerves, 496 

of nose, 283 * 

of ovaries, 421, 423 

of pancreas, 379 

of penis, 413 

of peritoneum, 385 

of pharynx, 322 

of pia, 475 

of pituitary body, 484 

of pleura, 312 

of prostate, 420 

of salivary glands, 323 

of seminal vesicles, 416 

of spinal cord, 489 

of spleen, 460, 464 

of stomach, 331 

of testicle, 415 

of thymus gland, 468 

of thyroid, 458 

of urethra, 411 

of uterus, 432 

of vagina, 436 

of vulva, 437 

predisposing causes of, 96 

teratoid, 131 

theories of origin, 95 
Twins, 24 
Tympanites, 353 
Typhlitis, 341 
Typhoid fever, 345 
bacillus of, 164 

ulcer, 347 
Tyroma, 475 

of brain, 483 



Ulcer, 78 

atheromatous, 276 

of intestine, 337 

rodent, 126 

typhoid, 347 
Ulceration of cervix, 432 
Ulcerative endocarditis, 271 

enteritis, 340 

stomatitis, 314 
Uncinaria americana, 204 

duodenalis, 202 
Union by first intention, 81 

by second intention, 81 
Unna's orcein stain, 243 
Uratic infiltration, 67 



522 



INDEX 



Uremia, 31 

Ureter, calculi in, 404 

diseases of, 402 

obstruction of, 401, 402 

parasites of, 404 
Urethra, inflammation of, 410 

injuries of, 411 

malformations of, 410 

tumors of, 411 
Urethral caruncle, 411 
Urethritis, 410 
Uric acid calculi, 408 
Urinary organs, diseases of, 385 
Uterus, adenocarcinoma of, 433 

adenoma of, 433 

adenosarcoma of, 433 

amyloid degeneration of, 429 

angiosarcoma of, 433 
anteflexion of, 427 

anteversion of, 427 

at autopsy, 216 

atresia of, 426 

atrophy of, 429 

carcinoma of, 434 

cysts of, 434 

dilatation of, 428 

epithelioma of, 434 

fatty degeneration of, 429 

fibroids of, 432 

hemorrhage of, 429 

hyperemia of, 428 

hypertrophy of, 429 

inflammation of, 430 

inversion of, 428 

malformations of, 426 

malpositions of, 427 

papilloma' of, 433 

prolapse, 428 

rupture of, 427 

sarcoma of, 433 

syphilis of, 432 

tuberculosis of, 432 

tumors of, 432 



Vagina at autopsy, 16 
inflammation of, 435 
malformations of, 434 
prolapse of, 435 
syphilis of, 436 
tuberculosis of, 436 
tumors of, 436 



Vagina, wounds of, 433 
Vaginal cystocele, 435 

rectocele, 435 
Vaginitis, 435 

testis, 416 
Van Gieson's method of staining, 

241 
Varicocele, 280 
Varicose veins, 280 
Varix, 280 

Vegetable parasites, 141 
Veins, inflammation of, 279 

varicose, 280 
Venous hyperemia, 39 
Verrucose endocarditis, 270 
Vesical calculi, 406 
Vesiculitis, 416 
Vibrio, 146 

Mctchnikovi, 168 

tyrogenum, 167 
Virchow's theory of tumor forma- 
tion, 95 
Viscerae, abnormal location of, 23 
Volvulus, 336 
Vulva, chancroid of, 437 

elephantiasis of, 437 

hyperemia of, 436 

inflammation of, 436 

syphilis of, 437 

tuberculosis of, 437 

tumors of, 437 

wounds of, 436 



Waxy casts, 397 

metamorphosis, 59 
Weigert's stain for elastic fibers, 243 
Whip-worm, 205 
White pneumonia, 306 

softening of brain, 481 
of spinal cord, 487 

thrombus, 43 
Whites, 435 
Widal reaction, 349 
Worms, 192 
Wounds of vagina, 435 

of vulva, 436 
Wright's blood-stain, 244 



I 



i 



Xanthix calculi, 408 
Xiphopagi, 24 



INDEX 



523 



X-rays, effect of, 20 



Yellow fever, parasite of, 190 
softening of brain, 481 
of spinal cord, 487 



Zenker's fluid, 226 

Ziehl-Xielson method of staining, 

252 
Zooglea, 146 
Zuckerguss organs, 382 
Zygote, 189 
Zymogens, 150 



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SURGERY AND ANATOMY. 13 

Lewis' Anatomy and Physiology for Nurses 

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McClellan's Art Anatomy Recently issued 

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Senn on Tumors second Revised Edition 

Pathology and Surgical Treatment of Tumors. Bv Nicholas 
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American Pocket Dictionary ^"""^efntit'llue^^^^^ 

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Beck's Fractures 

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i2mo, 278 pages, illustrated. ^1.50 net. 

" These subjects are treated most accurately and up to date, without the super- 
fluous reading which is so often employed. . . . Nurses will find this book of the 
greatest value " — Trained Nurse and Hospital Revieiu. 

Grant on Face, Mouth, and Jaws 

A Text-Book of the Surgical Principles and Surgical Dis- 
eases OF THE Face, Mouth, and Jaws. For Dental Students. By 
H. Horace Grant, A. M., M. D., Professor of Surgery and of Clinical 
Surgery, Hospital College of Medicine. Octavo of 231 pages, with 68 
illustrations. Cloth, ^2.50 net. 

" The language of the book is simple and clear. . . . We recommend the work to 
those for whom it is intended." — Philadelphia Medical fournal. 



I 



SURGERY AND ANATOMY 



c«««»o C-^'^..,, Based on the Author's 

Senn S Surgery 25 Years' Experience 

Practical Surgery, By N, Senn, M. D., Ph. D., LL. D., Pro- 
fessor of Surgery in Rush Medical College. Ociavo of 1133 pages, with 
650 illustration^, many in colors. Cloth, S6.00 net ; Half Morocco, 
$7.00 net. Subsn-iptioJi. 

"A record of the matured opinions and practice of an accomplished and exper- 
ienced surgeon."' — Annals of Surgery. 

Beck's Surgical Asepsis 

A Manual of Surgical Asepsis. By Carl Beck, M. D., Pro- 
fessor of Surgery, New York Post-graduate Medical School and Hos- 
pital. 306 pages ; 65 text-illustrations and 12 full-page plates. Cloth, 
Si. 25 net. 

Griffith's Hand-Book of Surgery Recently issued 

A Manual of Surgery. By Frederic R. Griffith, M. D., Sur- 
geon to the Bellevue Dispensary, New York City. i2mo of 579 pages, 
with 417 illustrations. Flexible leather, S2.00 net. 

" Well adapted to the needs of the student and to the busy practitioner for a hasty 
review of important points in surgery." — American Medicine. 

Keen's Addresses and Other Papers Just Ready 

ArjDRF„ssF.s AND Othf.r Papers. Delivered by \Villiam \V. Keen. 
M. D.. LL.D.. F. R. C. S. ^Hon.), Professor of the Principles of Surgen.- 
and of Clinical Surgen,-. Teffer>on Medical College. Philadelphia. Octavo 
volume of 441 pages, illustrated. Cloth. S3. 75 net. 

Senn*s Syllabus of Surgery 

A Syllabus of Lectures ox the Practice of Surgery. Ar- 
ranged in conformity with "American Text-Book of Surgery." By 
N1CHOLA.S Senn, M. D., Ph. D., LL. D., Professor of Surgerv', Rush 
Medical College, Chicago. Cloth, Si. 50 net. 

" The author has evidently spared no pains in making his Syllabus thoroughly com- 
prehensive, and has added new matter and alluded to the most recent authors and 
operations. Full references are also given to all requisite details of surgical anatomy 
and pathology." — British Medical Journal. 

Keen on the Surgery of Typhoid 

The Surgical Complications and Sequels of Typhoid Fever. 
By Wm. W. Keen. M. D., LL.D., F". R. C. S. (Hon.), Professor of 
the Principles of Surger}- and of Clinical Surgery, Jefferson Medical 
College, Philadelphia, etc. Octavo volume of 386 pages, illustrated. 
Cloth, $3.00 net. 

*• Ever>- surgical incident which can occur during or after typhoid fever is amply 
discussed and fully illustrated by cases. . . . The book will be useful both to the 
surgeon and physician " — The Practitioner, London. 



l6 SURGERY AND ANATOMY 

Moore's Orthopedic Surgery 

A Manual of Orthufeuic Surgery. By Jamks E. Moore, M. D., 
Professor of Clinical Surgery, University of Minnesota, College of Medi- 
cine and Surgery. Octavo of 356 pages, handsomely illustrated. Cloth, 
^2.50 net. 

" The book is eminently practical It is a safe guide in the understanding and treat- 
ment of orthopedic cases. Should be owned by every surgeon and practitioner." — 
Annals 0/ Surgery. 

Nancrede's Anatomy and Dissection. Fourth Edition 

Essentials of Anatomy and Manual of PKAniCAL Dissection. 
By Charles B. Nancrede, M. D., Professor of Surgery and of Clinical 
Surgery, University of Michigan, Ann Arbor. Post-octavo; 500 pages, 
with full-page lithographic plates in colors, and nearly 200 illustrations. 
Extra Cloth (or Oilcloth for the dissecting-room), ^2.00 net. 

•' The plates are of more than ordinary excellence, and are of especial value to 
students in their work in the d\ss&cim%-room."— Journal 0/ the American Medical 
Association. t x » i 

_- ,,_.., - _ Just Issued 

Nancrede s Principles of Surgery New (2d) Edition 

Lectures on the Principlks of Surcery. By Chari.es B. Nan- 
crede, M. D., LL. D., Professor of Surgery and of Clinical Surgery, 
University of Michigan, Ann Arbor. Octavo, 407 pages, illustrated. 
Cloth, ^2.50 net. 

" We can strongly recommend this book to all students and those who would see 
something of the scientific foundation upon which the art of suigery is built." — 
Quarterly Medical Journal, Sheffield, En inland. _ , 

Recently Issued 

Nancrede s Essentials of Anatomy. 7th Edition 

Essentials of Anaidmy, inckuling the Anatomy of the Viscera. 
By Charles B. Nancrkde, M. D., Professor of Surgery and of Clinical 
Surgery, University of Michigan, Ann Arbor. Crown octavo, 388 pages, 
180 cuts. With an Apjiendix containing over 60 illustrations of the 
osteology of the body. Based on Gray''s Anatomy. Cloth, ^i.oo net. 
In Saunders' Question Covipends. 

" The questions have been wisely selected, and the answers accurately and con- 
cisely given." — Uniz'ersity Medical Magazine. 

Martin's Essentials of Surgery. Seventh Revised Edition 

Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
cal Landmarks, Minor and Operative Surgery, and a complete description, 
with illustrations, of the Handkerchief and Roller Bandages. By Ed- 
ward Martin, A.M., M. D., Professor of Clinical Surgery, University 
of Pennsylvania, etc. Crown octavo, 'i,'},^ pages, illustrated. With an 
Appendix on Antiseptic Surgery, etc. Cloth, ;^i.oo net. In Saunders' 
Question Compends. 

Martin's Essentials of Minor Surgery, Bandas>ing, 

and Venereal Diseases. Second Revised Edition 

Essentials of Minor Surgery, Bandaginc;, and Venereal Dis- 
eases. By Edward Martin, A. M., M. D., Professor of Clinical Sur- 
gery, University of Pennsylvania, etc. Crown octavo, 166 pages, with 
78 illustrations. Cloth, $1.00 net. In Saunders' Question Compends. 



i-RB S 'li, 



